Form 6: Application For A Licence To Use Radiation Apparatus - Dental Purposes Page 3
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3Fees to accompany application
Note: Persons who require a licence to use a radiation source for dental purposes in the course of the person’s study or training at
an educational institution are not required to pay application or licence fees for the licence.
To claim this exemption from the requirement to pay fees, the applicant must provide evidence of enrolment.
Schedule of Fees
These fees are effective as of 1 October 2015.
Student—up to 3 year licence—no fee required
Holder of a current licence—no fee required
New licence applicants:
New licence up to 1 year – please pay $146.50 ($85.50 application fee + $61.00 licence fee)
New licence up to 2 years – please pay $207.50 ($85.50 application fee + $122.00 licence fee)
New licence up to 3 years – please pay $268.50 ($85.50 application fee + $183.00 licence fee)
The application fee of $85.50 (included in above costs) is not refundable if this application is not successful.
Payment Details
(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 below)
Credit Card payments
(Complete this section if you wish to pay the fees for this application by MasterCard or Visa Card.)
Name of Applicant
(The name stated here should be the same as the name stated in section 1 on the application form.)
$
MasterCard
Visa Card
Please charge the fees payable
to my
Name on card
(Please print)
Card Number
Expiry Date
Date
Signature of cardholder
DO NOT EMAIL THIS PAGE
Important Note:
To ensure your credit card details remain secure, please do not email this page to the department. Your application,
with payment, should only be faxed or posted. Security cannot be guaranteed if this page is emailed.
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