Form 6: Application For A Licence To Use Radiation Apparatus - Dental Purposes Page 2

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= FAST TRACK =

RADIATION SAFETY ACT 1999

Application for a Licence to Use Radiation

Apparatus - Dental Purposes

To: The Chief Executive

APPLICANT DETAILS

Title and surname:

Given name(s):

Date of Birth:

Current Licence No.(if applicable):

Residential Address

Address:

Suburb:

State:

Country:

Post Code:

Postal Address (address for correspondence—if same as residential address, type ‘AS ABOVE’)

Address:

Suburb:

State:

Country:

Post Code:

Telephone Number (work)

E-mail Address

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

QUALIFICATIONS AND TRAINING

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.

Select type of radiation apparatus to be used and your qualifications/training

If your qualifications or training do not appear in the relevant drop down list, please complete Form 2—Application for a licence to use a radiation

source. Certified copy of your qualifications, training certificates or verification of enrolment as a student must accompany your application

Intra-oral dental diagnostic X-ray units

Evidence included?

Extra-oral dental diagnostic X-ray units

Evidence included?

Dental cone beam computed tomography X-ray units

Evidence included?

Laser apparatus

Evidence included?

Do you currently hold a similar licence issued by another jurisdiction?

If yes, please provide a full copy of your licence with your application

AHPRA PROFESSIONAL REGISTRATION NUMBER:

DEN

(n/a for dental assistants/students)

TERM/COST OF LICENCE REQUIRED:

DECLARATION

Have you been convicted of an indictable offence?

Yes

Have you been convicted of an offence against this Act or a corresponding law?

Yes

Have you held a licence under this Act, or a similar instrument under a corresponding law, that was suspended or cancelled?

Yes

If the answer is yes to any of the above, please provide details:

IDENTIFICATION

One certified copy of a document from Requirement 1 & one certified copy of a document from Requirement 2 must accompany your application

Requirement 1:

Evidence included?

Requirement 2:

Evidence included?

‘Certified copy’ means a copy of an original document that has been certified by a justice of the peace or a notary public as being a correct copy of the original

document. Copies certified by a Commissioner for Declarations as defined in Queensland’s Justices of the Peace and Commissioners for Declarations Act 1991

WILL NOT be accepted.

Signature of Applicant:

___________________________________________

Date:

____/____/________

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Form 6 Version 1.8