Application For A Dangerous Goods Site Licence - Government Of Western Australia Page 13

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Application section – return to Resources Safety
Application no. (office use only)
DGS
Application for a
dangerous goods site licence
Dangerous Goods Safety Act 2004
Dangerous Goods Safety (Storage and Handling of Non-explosives)
Regulations 2007
ABN: 69 410 335 356
1. Application type
(you must tick one of the boxes)
New licence (N)
Additions (A)
Transfer only (T)
Reduction (R)
For A, T or R licence applications please indicate the licence number DGS
Do you want a common expiry date?
Yes
No
If you want this licence to be aligned with your common expiry date,
/
/
please provide your existing licence expiry date
2. Applicant details
Please tick one of the following boxes and complete the relevant sections below:
Body corporate
Partnership
Individual
Trust
_________________________________________________________________________________________________
Body corporate
(name as shown on certificate of incorporation)
ACN
_________________________________________________________________________________________________
• Individuals
• Partnerships
(names of all partners)
• Trusts
(name of at least one trustee)
Family name
Given names
(if insufficient space please attach a separate sheet)
An application from a partnership must include:
• a certified copy of evidence of the partnership; and
• a statutory declaration from each partner stating:
- the name of the partnership
- the name, home address and contact details of all partners; and
- the business in which the partnership is engaged
An application from a trust must include a certified copy of a document which states the name of the trust
Name of the registered business or firm, partnership or trust
DGS REV 2
100 Plain Street, East Perth WA 6004
Telephone: 08 9358 8001
Fax: 08 9358 8000

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