Application for a licence to the Chief Health Officer
Before you fill in the form
The fee for this licence is 100 revenue units per application, the unit price is determined by the Territory Revenue Office. Payment can be made to the “Receiver of Territory Monies”
(RTM) at (08) 8999 1606.
Employees of the Northern Territory Government are exempt from paying the fee.
ABN 84 085 734 992.
For further information and submitting applications contact Radiation Protection on (08) 8922 7152 or email [email protected] PO Box 40596, Casuarina NT 0811.
Payment Details Amount
Paid
Receipt Number
Date of Payment
Application Information
Provide previous licence number, if applicable Name
(Title and Full Name)
Date of Birth
Applicants
Signature Date
Telephone
No. Mobile No. Facsimile
No.
Applicant’s email address:
Name of Workplace Address of workplace Company ABN:
Address for correspondence:
Name of current position
Experience and Qualifications:
(Attach evidence)
Department of HEALTH Page 1 of 2
Application for a licence to the Chief Health Officer Select from the following list: use, acquire, 3 sell, manufacture, store,
transport, or otherwise deal with a radiation source4. Select only those activities that are relevant for your application.
Please provide a brief statement on the nature of your work:
Department of Health Page 2 of 2
