application pyrotechnicians licence 0885

8/2/2019 Application Pyrotechnicians Licence 0885

1/13

Application or pyrotechnicians licence

EX PYR

November 2010

Page 1 o 13

This orm is to be used to apply or a new application or the renewal o a Pyrotechnicians Licence under the ExplosivesRegulation 2005 (NSW).

Only individuals 18 years o age or over may apply.

The applicant must provide proo o identity documents to the value o at least 100 points to Australia Post at the time o lodgingthis application.

More inormation about applying or a Pyrotechnicians Licence is contained in the Guide or pyrotechnicians licence applicants.

Fee

$250 is payable on lodgement o this application with Australia Post.

I you are also lodging an application or an Unsupervised Handling Licence (UHL) you must pay an additional $150 or the UHLapplication.

How to fll in this orm

Please use black ink only and print within the boxes in BLOCK LETTERS.

Where options are provided, please mark box(es) with an to indicate selection(s).

Enquiries 13 10 50

Identifcation documents

Primary identifcation documents only one can be used

Birth Certifcate, Citizenship Certifcate or passport (passport must be current or expired within thelast two (2) years, but not cancelled). 70 points

Secondary identifcation documents

A licence issued under Australian law (eg drivers permit or licence), which contains a photographor signature. 40 points

Student card issued by a tertiary institution. 40 points

Utility bill in applicants name (eg council rates notice, water, power or phone account). 25 points

Medicare card. 25 points

Credit or debit card, passbook or account statement rom a fnancial institution. (Only one per fnancial

institution can be counted.) 25 points

Privacy compliance statement

This inormation is collected by WorkCover NSW (WorkCover) or the purposes o undertaking an evaluation, assessment andprocessing o an application or a pyrotechnicans licence as required by the Explosives Act 2003 (NSW)and the ExplosivesRegulation 2005 (NSW).

This inormation will also be used by WorkCover or the purposes o confrming applicant details and it may be used to establishand maintain a database and to assist WorkCover and its inspectorate with its work generally. It may also be provided to otherState and Territory agencies.

Except or the purpose o prosecution and unless such disclosure is otherwise required or permitted by law, the inormation willnot be otherwise accessed by any third parties in a way that would identiy the individual, without the consent o that individual.Applicants are able to gain access to personal inormation pertaining to their application that is held by WorkCover. You may also

apply to WorkCover to access and correct any inormation about yoursel that WorkCover holds i that inormation is inaccurate,incomplete, not relevant or out o date. Applications should be made in writing to: Privacy Contact Ofcer, WorkCover NSW,Locked Bag 2906, Lisarow, NSW 2252.

Explosives Act 2003 (NSW) Explosives Regulation 2005 (NSW)


2/13

1. APPLICATION TYPE

For renewals where no details have changed complete sections 1, 2 that are marked with an asterisk and 10, alsocomplete section 9.4 and 9.5 i the licence is authorised or storage.

New application. Renewal. Please provide your licence details and answer the ollowing.

Licence number Expiry date

/ / Name on the licence

Are you requesting additional types o freworks or adding or changing your storage? Yes No

2. APPLICANT DETAILS

*Title *Family/Surname

*Given name

*Other names

*Date o birth (DD/MM/YYYY)

*Sex Male Female / / Daytime contact number Mobile number Fax number

Email

Language spoken at home (optional)

*Address details (must NOT be a PO Box)

Unit number/Street number/Property number (include Lot or DP i applicable)

Street name

Suburb State Postcode

Australia Post use only

Document type Date of issue State of issue Documentation number Expiry date Point value

Point total

Name o Australia Post Checking Ofcer Name o Post Ofce/Agency

Signature Date (DD/MM/YYYY)

/ /

Australia Post disclaimer Australia Post is acting as an agent or WorkCover to identiy you under the requirements set out by the Explosives Act 2003.

Your application will be orwarded to WorkCover who will determine whether a licence will be granted.

WorkCover is required, under the Explosives Act 2003, to provide licensees with certain inormation. This inormation will be sent to you when and i your

application is approved.

Application or a pyrotechnicians licence EX PYR

Page 2 o 13


3/13

Postal address

Same as address on previous page or provide a postal address.

Unit number/Street number/Property number (include Lot or DP/PO Box/GPO Box/Private Bag/Locked Bag)

Street name


Will you be trading under a business or trading name?

Yes. Please provide the ollowing. No. Please go to section 3.

Registered business (trading) name

ABN

- - -

3. UNSUPERVISED HANDLING LICENCE

You must hold a current unsupervised handling licence (UHL) or apply or a UHL at the same time as the application or

Blasting Explosive User Licence.

Provide the current UHL number and expiry date

Licence number Expiry date

/ / OR

I have attached an application or a UHL to this application orm.

4. REASON FOR REQUESTING A PYROTECHNICANS LICENCE

Please indicate the type(s) o displays or which you require authorisation.

Organised public displays.

Theatrical displays.

Technical non-displays.

Model rocket with propellant device containing an ignitable substance greater than 62.5 grams.

I technical non-display you must provide a reason (reer to section 2.3 o the Operational conditions freworks pyrotechnics andsingle use licence holders).


Page 3 o 13


4/13

5. TYPES OF FIREWORKS FOR WHICH AUTHORISATION IS SOUGHT

Reer to the Guide for pyrotechnicans licence applicantsor the experience required or each type o freworks.

Ground display.

Chinese string freworks.

Theatrical/indoor.

Aerial shells up to 75mm 100mm 150mm 200mm 300mm.

Aerial salutes up to 75mm.

Model rocket with propellant device containing an ignitable substance greater than 62.5 grams.

6. EXPERIENCE

You must ensure that a licence holder who has supervised you during freworks displays completes the statutory

declaration on the last page o this application or provide details o a current or expired equivalent interstate licence or

details o a General Permit issued by WorkCover NSW.

Statutory declaration completed.

Current or expired equivalent interstate licence or previously issued General Permit. Please provide details in section 7.

7. OTHER EXPLOSIVES LICENCE

State/TerritoryType o licence Licence number Expiry date o issue

/ /

/ /

/ /

/ /

8. FURTHER INFORMATION

Have you been convicted o an oence under the Occupational Health and Safety Act 2000and/or the OccupationalHealth and Safety Regulation 2001 and/or the Explosives Act 2003and/or the Explosives Regulation 2005and/or the

Construction Safety Act 1912and/or the Dangerous Goods Act 1975or any other equivalent legislation in any State or

Territory in Australia or elsewhere in the last 10 years?

Yes. Provide details o the date o conviction, oence and the result and/or penalty.

No. Please go to section 9.


Page 4 o 13


5/13

9. STORAGE OF FIREWORKS

Reer to the Guide for pyrotechnicians licence applicantsor more inormation about storage requirements.

Do you intend to store freworks?

Yes. Please complete sections 9.1 9.5

No. Please go to section 10.

9.1 Site address where explosives are to be stored

A photocopy o a street directory map or other map showing the locality o the site with an X must be submitted with a newapplication only.

I have attached a photocopy rom a local street directory or other map with the locality o the site indicated by an X.

Street number (include Lot or DP number i applicable)

Street name


Nearest cross street

9.2 Site stafng details

Is the site staed? Yes. Please complete the ollowing No. Please go to section 9.3.

Number o sta on site Hours per day Days per week

9.3 Emergency ater hours persons contact details

Same as individual applicant, please provide the ater hours contact telephone number below or i a dierent ater hourscontact person, provide all details.

Title Family/Surname

Given name

Daytime contact number Mobile number Fax number

Ater hours telephone number

9.4 Security plan

You must attach a security plan or a new application or a renewal where the licence is authorised or storage. Please

reer to the WorkCover NSW publication Security plan for the storage and handling of explosives (including explosiveprecursors) guide.

Note: The security plan includes a Site Sketch.

I have attached a security plan.


Page 5 o 13


6/13

9.5 Details o explosives to be stored

You must provide details o each magazine and all explosives stored within the magazine(s) or a new application or

renewals where the licence is authorised or storage. I space is insufcient please photocopy this page and submit with

this application orm.

Storage acility ormagazine identifer Type o storage acility

Class or division Maximum storage capacity Unit (L or kg or number)

UN number Class or division Typical quantity Unit (L, tonnes, kg/NEQ, m3 or number)

Proper shipping name

Product or common name











Page 6 o 13


7/13


Page 7 o 13



UN number Class or division Typical quantity Unit (L, tonnes, kg/NEQ, m3

or number)













8/13


Page 8 o 13




or number)













9/13


Page 8 o 13




or number)













10/13


Page 9 o 13

10. DECLARATION

I declare and acknowledge that:

I am 18 years o age or over.

The inormation contained in this application is true and correct in every particular.

I consent to the making o inquiries and the exchange o inormation with, the authorities o any State or Territory regarding

any matter relevant to this application.

I am aware that i WorkCover NSW is notifed by security authorities o a change in my security status the licence may besuspended or cancelled and my employer may be notifed.

I am aware that it is an oence under section 18(2) o the Explosives Act 2003 (NSW)to provide any inormation orproduce any documentation that I know is alse or misleading and that a licence issued based on alse or misleadinginormation may be suspended or cancelled.

I agree to comply with the Explosive Act 2003 (NSW), the Explosives Regulation 2005 (NSW)and all conditions o thelicence i this application is successul.

Signature o applicant Date (DD/MM/YYYY)

/ /

11. CHECKLIST

You must possess a current Unsupervised Handling Licence (UHL) or you can apply or one at the same time as aPyrotechnicians licence but the latter will not be processed until the UHL is approved.

Statutory declaration, where applicable, reer to section 6 o this application orm.

Photocopy o a street directory map or other map showing the locality o the site with an X is required i storage has beenrequested, reer to section 9.1 o this orm. Only required or new applications.

Security plan is required i storage o freworks has been requested reer to section 9.4 o this application orm. Submit asecurity plan or both a new application where storage is requested and renewals where the licence has been authorised orstorage.

Proo o identity to the value o at least 100 points must be shown to Australia Post sta when submitting this applicationorm.

Fee o $250 must be paid when submitting this application orm to Australia Post. I you are also submitting an UHLapplication the ee payable is $400.

12. LODGEMENT

At any Australia Post Bank@Post outlet.


11/13

COMMONWEALTH OF AUSTRALIA STATUTORY DECLARATION (Statutory Declarations Act 1959)

1 Insert the name,

address and

licence number

o the licence

holder making the

declaration.

I, (insert name, address, licence number o the licence holder making the declaration here)

1

make the ollowing declaration under the Statutory Declarations Act 1959:

2 Insert applicants

name and mark

the freworks

types or which

you have provided

instruction and

supervision.

I have instructed2

(insert the applicants name)in the sae use o the ollowing types o freworks (mark the freworks types or which you providedinstruction):

Ground display freworks.

Theatrical/close proximity freworks.

Chinese string freworks.

Aerial display shells to mm.

Aerial salutes up to 75mm.

He/she has fred these freworks under my direct supervision* at the ollowing displays (please complete thetable below) and I have determined that the applicant is competent in the use o the nominated freworks.

Date Name of event

*Direct supervision means being supervised by a competent licensed person in charge o a display who ensures: the applicant is within

sight and sound, a risk assessment is undertaken by the applicant, sae work method statements were undertaken by the applicant.

I understand that a person who intentionally makes a alse statement in a statutory declaration is guilty oan oence under section 10 o the Statutory Declarations Act 1959, and I believe that the statements inthis declaration are true in every particular.

3 Signature o

person making

the declaration.

3

4 Place

5 Day

6 Month and year

Declared at4

on5

o6

7 Signature o

person beore

whom the

declaration is

made (see over).

Beore me,

7

8 Full name,

qualifcation and

address o person

beore whom

the declaration is

made (in printed

letters).

8


Page 11 o 13


12/13


13/13

Catalogue No. WC00885 WorkCover Publications Hotline 1300 799 003

WorkCover NSW, 92-100 Donnison Street, Gosord, NSW 2250

Locked Bag 2906, Lisarow, NSW 2252 | WorkCover Assistance Service 13 10 50

Website workcover.nsw.gov.au

ISBN 978 1 74218 870 6 Copyright WorkCover NSW 0911

Holder o a statutory ofce not specifed in another item in this list:

Judge o a court

Justice o the Peace

Magistrate

Marriage celebrant registered under Subdivision C o Division 1 o Part IV o the Marriage Act 1961

Master o a court

Member o Chartered Secretaries Australia

Member o Engineers Australia, other than at the grade o student

Member o the Association o Taxation and Management Accountants

Member o the Australasian Institute o Mining and Metallurgy

Member o the Australian Deence Force who is:

a. an ofcer

b. a non-commissioned ofcer within the meaning o the Deence Force Discipline Act 1982with fve (5) or more years ocontinuous service

c. a warrant ofcer within the meaning o that Act

Member o the Institute o Chartered Accountants in Australia, the Australian Society o Certifed Practising Accountants orthe National Institute o Accountants

Member o:

a. the Parliament o the Commonwealth

b. the Parliament o a State

c. a Territory legislature

d. a local government authority o a State or Territory

Minister o religion registered under Subdivision A o Division 1 o Part IV o the Marriage Act 1961

Notary public

Permanent employee o the Australian Postal Corporation with fve (5) or more years o continuous service who isemployed in an ofce supplying postal services to the public

Permanent employee o:

a. the Commonwealth or a Commonwealth authority

b. a State or Territory or a State or Territory authority

c. a local government authority, with fve (5) or more years o continuous service who is not specifed in another item inthis list

Person beore whom a statutory declaration may be made under the law o the State or Territory in which the declaration ismade

Police ofcer

Registrar, or Deputy Registrar, o a court

Senior Executive Service employee o:

a. the Commonwealth or a Commonwealth authority

b. a State or Territory or a State or Territory authority

Sheri, Sheris ofcer

Teacher employed on a ull-time basis at a school or tertiary education institution


application pyrotechnicians licence 0885

Documents