How to Submit the Application: Please post or fax your signed and completed application form, associated documentation (see 3 above) and credit card payment form or cheque/money order to: The Chief Executive c/- Radiation Health Licensing

Health Protection Branch Queensland Department of Health PO Box 2368 FORTITUDE VALLEY BC QLD 4006 or Facsimile: 07 3328 9622

Note to Applicant: The Information Privacy Act 2009 sets out the rules for the collection and handling of personal information by the Department of Health. For information about how the Department of Health protects your personal information, or to learn about your right to access your own personal information, please see our website at www.health.qld.gov.au.

General Information: 1. The attached application form is intended to be used by persons seeking to hold an

accreditation certificate. 2. The application form is to be completed in all respects, then printed. Both pages of the

application must be signed and dated before being posted or faxed. 3. The following documents are to be submitted with the application:

(i) a certified copy of your qualifications and training certificate

(ii) supporting evidence of your skills, competency, knowledge and experience 4. The correct fee is to be submitted with the application—failure to do this will result in your

application not being accepted. Note: The application fee is not refundable if this application is not successful.

FORM 10: Application for an Accreditation Certificate

RADIATION SAFETY ACT 1999

Application for an Accreditation Certificate

To the Chief Executive: 1. Name of Applicant (include full name and title) Address (for correspondence) 2. 3. Telephone Number (work) Fax Number E-mail Address

Please note: Your contact details will appear on a publicly available register. 4. Qualifications/Training (include a certified copy of your qualifications and/or other certificate(s) relevant to this application)

5. Skills, competency, knowledge, experience (include supporting documentation as verification) 6. Type of radiation source or premises for which you wish to issue a certificate of compliance (please tick the appropriate box on the next page) 7. Have you a) been convicted of an indictable offence? Yes No b) been convicted of an offence against this Act or a corresponding law? Yes No c) held a certificate under this Act, or a similar instrument under a Yes No corresponding law, that was suspended or cancelled? If the answer is “yes” to any of the above, please attach details. 8. Please state the term of the certificate you are seeking (Choose 1, 2 or 3 years only.)

Signature of Applicant: Date:

Please turn over

Client Number

Title Surname Given name(s)

Postcode

years

9. Payment of fees (Please note that this application will not be complete unless the appropriate fees are included when the application is made.)

The fees payable with this application have been calculated by the applicant to be

Payment information (Note: This is a GST free item. Queensland Health ABN: 66 329 169 412)

Cheque or Money Order enclosed (payable to Queensland Health)

Payment by Credit Card (Please complete the ‘Credit Card Payments’ section on the page attached to this form)

$

Form 10 Version 1.7 Page 1 of 2

Privacy Statement: The Department of Health provides this form under the Radiation Safety Act 1999 so that you may apply for an Act Instrument. The information and documents collected for the purpose of this application may be accessible by authorised departmental persons. Licence details of successful applicants will be publicly available on the department’s register of holders of licences and certificates as required by the Act. The department will not disclose your personal information or supporting documents to third parties without your consent unless required or authorised by law.

Type of compliance certificate the applicant intends to be allowed to issue—please tick only one box

Radiation sources—health care related Radiation apparatus used to carry out diagnostic radiography, excluding computed tomography, mammography,

fluoroscopy and intra-oral dental diagnostic radiography Radiation apparatus used to carry out fluoroscopy Radiation apparatus used to carry out computed tomography Radiation apparatus used to carry out film-screen mammography Radiation apparatus used to carry out intra-oral dental diagnostic radiography Laser apparatus used to carry out cosmetic or health related procedures on human beings Radiation sources—non-health care related Radiation apparatus used to carry out plain film radiography of inanimate objects Cabinet radiation apparatus used to carry out fluoroscopic or radiographic imaging of inanimate objects Radiation apparatus used to carry out diagnostic radiography of animals Radiation apparatus used to carry out industrial radiography Radiation apparatus used to carry out chemical analysis Radiation apparatus used to carry out industrial gauging Sealed radioactive substances incorporated in sealed source apparatus used to carry out industrial radiography Sealed radioactive substances incorporated in sealed source apparatus used to carry out chemical analysis Sealed radioactive substances incorporated in sealed source apparatus used to carry out industrial gauging Sealed radioactive substances incorporated in sealed source apparatus used to carry out borehole logging

Sealed radioactive substances incorporated in sealed source apparatus used to carry out moisture/density

measurements Radiation apparatus used to carry out sterilisation Sealed radioactive substances incorporated in sealed source apparatus used to carry out irradiation Premises Premises at which a laser apparatus is used to carry out cosmetic or health related procedures Premises at which a radioactive substance is stored Premises at which a radiation apparatus is used to carry out diagnostic radiography (including veterinary radiography)

Premises at which a radiation apparatus is used to carry out radiation therapy (including veterinary radiation therapy)

Premises at which a radioactive substance is used to carry out high or pulsed rate brachytherapy Premises at which a radiation apparatus is used to carry out chemical analysis Premises at which a radiation source is used to carry out industrial gauging Premises at which a radiation source is used to carry out industrial radiography, excluding open sites Premises at which a radiation source is used as part of a nuclear medicine practice Other—please specify:

Signature of Applicant: Date:

Page 2 of 2

The Information Privacy Act 2009 sets out the rules for the collection and handling of personal information by the Department of Health. For information about how the Department of Health protects your personal information, or to learn about your right to access your own personal information, please see our website at www.health.qld.gov.au.

Client Number

Note for the applicant

Fees to accompany application Schedule of Fees These fees are effective as of 1 October 2019.

Holder of a current certificate—please pay the application fee of $276.00 New certificate up to 1 year—please pay $414.00 ($276.00 application fee + $138.00 certificate fee) New certificate up to 2 years—please pay $552.00 ($276.00 application fee + $276.00 certificate fee) New certificate up to 3 years—please pay $690.00 ($276.00 application fee + $414.00 certificate fee) The application fee of $276.00 (included in above costs) is not refundable if this application is not successful.

Payment Options

(Note: This is a GST free item. Queensland Health ABN: 66 329 169 412)

Note: Your application will not be accepted unless payment is provided.

Payment of your application may be via one of the following options:

• Cheque or Money Order (payable to Queensland Health) — attach to your completed application

• Credit Card — complete the ‘Credit Card Payments’ section below and submit with your

completed application

Applicants applying to renew a licence or renew a certificate, or who are applying for approval to acquire or

an approval to relocate a radiation source may also pay by credit card via:

• B-Point — pay online at www.bpoint.com.au/payments/qldradiationlicences — submit a copy of

your BPoint Payment Receipt with your completed application

Credit Card Payments

IF YOU ARE COMPLETING THIS SECTION, DO NOT EMAIL THIS PAGE AS SECURITY OF YOUR CREDIT CARD

INFORMATION CANNOT BE ASSURED

Name of Applicant (The name stated here should be the same as the name stated in section 1 on the application form.)

Please charge the fees payable to my

Name on card (Please print)

Card number Expiry date

$ MasterCard Visa Card

Signature of cardholder Date