Application for a dangerous goods drivers licence

22 February 2023 | Version 9.0

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Application for a dangerous goods drivers licence –

Class 2 to 9

Use this form to apply for a dangerous goods drivers licence class 2 to 9 and/or class 5 (excluding 7) issued

under Regulation 156 of the Transport of Dangerous Goods by Road and Rail (National Uniform Legislation)

Regulations 2011.

If you require a licence to transport class 1 explosives you will need to complete the application for a

dangerous goods driver licence - class 1 explosives. Refer to the Dangerous Goods Transport – Class 1

Explosives bulletin for further information. For the relevant application fee, visit the licensing fees and

charges webpage.

Application type: New ☐ Renewal ☐

Licence type: Class 2 to 9 (excluding class 7 and SSAN) ☐ Class 2 to 9 (excluding class 7) ☐

1. Licence details (Renewal only)

DG Drivers licence number:

Expiry date:

2. Applicant details

Surname:

Given names:

Date of birth:

Residential address:

Suburb:

State:

Postcode:

Is your postal address the same as above? If no, complete below:

Yes

☐

Postal address:

Suburb:

State:

Postcode:

Home number:

Mobile number:

Email address:

3. Competency training (not more than 6 months old at time of application)

Attached evidence of competency training TLILIC0001 - Licence to transport dangerous goods by road

☐

4. Medical assessment of fitness to drive (not more than 6 months old at time of application)

I have attached a completed medical condition notification form (Assessing Fitness to Drive for Commercial

and Private Vehicle Drivers 2022). The approved form is available on NT WorkSafe’s website.

☐

5. Driving record (please tick relevant options)

I have not held a drivers licence in a State/Territory other than the NT within the past 5 years;

☐

1. I authorise NT Worksafe to access

a) Driver licence information, which includes personal and sensitive information, kept by the Northern

Territory Motor Vehicle Registry where I am licensed to drive; and

b) Records of convictions for any driving offences recorded against my driver’s licence

☐

2. I have supplied a current certified extract of entries from the NT Motor Vehicle Registry

☐

I have held a drivers licence in another State/Territory in the past 5 years. You must supply an extract of

entries from the driver licensing authority in each State/Territory where you have held a licence to drive.

☐

Please indicate the jurisdiction in Australia where you have held a licence to drive within the past five (5) years.

☐

ACT

☐

NSW

☐

QLD

☐

VIC

☐

TAS

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Application for a dangerous goods drivers licence – Class 2 to 9

NT WorkSafe

22 February 2023 | Version 9.0

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6. Security sensitive ammonium nitrate (SSAN) – (Complete below if you are required to transport SSAN (Class 5))

Attached letter from current employer stating transport of SSAN is a requirement of employment conditions

☐

Current employer:

Phone number:

7. Criminal history check (only required if transporting SSAN, must not be more than 6 months old at time of application)

Attach a completed criminal history finger print check - (New only)

☐

Attach a completed criminal history name check - (Renewal only)

☐

Note: A current Dangerous Goods Security Card can be accepted in place of a criminal history check.

8. Disclosure of information

Are you currently under investigation or pending a hearing before a court or Regulatory

Authority? (If yes, please complete below)

Yes

☐

Have you ever been convicted or found guilty of any offence (regardless if a conviction was

recorded) within the last 10 years in the Northern Territory, another State, Territory or

Commonwealth? (If yes, please provide details below)

Yes

☐

9. Proof of identity (ID)

Applicants must attach either one of the following combinations:

 One primary and two secondary documents; or

 Two primary and one secondary documents from the list below.

You must include your driver licence as one type of primary ID. If you are unable to provide the required documents please

contact NT WorkSafe.

Primary document

Select

Australian birth certificate/card

☐

Australian passport (note: passports are still valid for 2 years after expiry, unless cancelled)

☐

Australian citizenship certificate

☐

Australian drivers licence

☐

Licence or permit issued by the Commonwealth, State or Territory government that has your DOB and photo

i.e HRWL licence, working with children’s card etc

☐

Proof of Age Card issued by an Australian State or Territory

☐

Identity document issued by an Aboriginal Land Council that has your photograph

☐

Secondary document

Select

Photo ID card showing you are a Commonwealth, State or Territory Government employee

☐

Medicare, centrelink or health care card

☐

Credit card or debit card – one per bank only

☐

Council rates notice with your name and current residential address

☐

Utilities notice with your name and current residential address

☐

Foreign drivers licence

☐

Application for a dangerous goods drivers licence – Class 2 to 9

NT WorkSafe

22 February 2023 | Version 9.0

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10. Receiving licence

How do you wish to receive the licence?

Post

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Collection

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11. Applicant declaration

The information in this application is true and correct to the best of my knowledge.

I consent to the Work Health Authority making enquiries and exchanging information with WHS regulators in other States,

Territories or the Commonwealth regarding any matter relevant to this application. NT WorkSafe may also disclose your licence

status to third parties who wish to verify your licence. Licence status refers to the issue and expiry date as well as any classes or

conditions of your licence.

Applicant name:

Applicant signature:

Date:

Checklist

Licence requirements

New/Renewal

Application is complete and signed

☐

A passport-size photo not more than 6 months old. Alternatively, photos can be taken at any TBC

☐

Prescribed application fee (see licensing fees and charges page)

☐

Proof of ID attached (note: you must supply a current copy of your driver’s licence as part of your 3 points of ID)

☐

Evidence of competency training - TLILIC0001 Licence to transport dangerous goods by road attached

(not more than 6 months old at time of application)

☐

Medical condition notification form attached (not more than 6 months old at time of application)

☐

Section 5 driving records completed and any records attached if applicable

☐

SSAN only – Criminal history attached – fingerprint (new) or name check (renewal)

(not more than 6 months old at time of application)

☐

SSAN only – Attached letter from current employer as per section 6

☐

Privacy statement

The Department of Attorney-General and Justice complies with the Information Privacy Principles scheduled to the

Information Act 2002.

Lodgement

Complete applications can be lodged in person, email or via post at a Territory Business Centre below:

Darwin

Darwin Corporate Park, Building 3, 631 Stuart Highway Berrimah

Katherine

Big Rivers Government Centre - 5 First Street, Katherine

Alice Springs

Ground floor, The Green Well building, 50 Bath Street

Tennant Creek

Shop 2, Barkly House, Cnr Davidson and Patterson Street

Phone: 1800 193 111

Email: territorybusines[email protected]

Postal: GPO Box 9800, Darwin, NT 0801

Payment details

A fee is payable on lodgement of this application form. Payment can be made by:

 Cash (in person only); or

 Cheque (made out to Receiver of Territory Monies); or

 Credit card (Visa or MasterCard accepted in person or over the phone). Note: A staff member from the Territory

Business Centre will contact you via phone for payment.

Payment date:

Receipt number:

Amount paid: