Licence No: (Office Use Only) APPLICATION FOR GAS WORK LICENCE (HYDROCARBON REFRIGERANTS) Petroleum and Gas (Production and Safety) Regulation 2004 Approved Form PGA728LH Version Number 7 $ OFFICIAL USE ONLY RECEIVED AT CRO; HO Date and Time / / : am / pm Application Fee $ Receipt Number Annual Fee Pursuant to s728 the Chief Inspector, Petroleum and Gas may, subject to a Regulation, issue a Gas Work Licence. This form should be used for all applications for a hydrocarbon refrigerant gas work licence, including subsequent applications (reapplications). Each individual wanting to undertake hydrocarbon refrigerant gas work must complete a separate application. The original completed application and all supporting documentation must be submitted. Faxed or emailed applications will not be accepted. All sections must be completed. Please print clearly in ink and use block letters. Fees are listed on page 4 and must accompany this application. Entered on database by APPLICATION TYPE (Please tick) (Name and signature) DATE: / / APPROVAL / REJECTION Installing Testing Removing Certifying Altering Repairing Servicing Interim Full First Application (All sections to be completed) Subsequent Application (Reapplication) (All sections to be completed) Change of Scope of Work (Sections 1, 3, 5.2, 5.3 & 6 to be completed. Application fee applies and original licence to be returned. SECTION 1 APPLICANT DETAILS Applicant s Full Name: Residential Address: Stationary Refrigeration (domestic/commercial) Stationary air conditioning gas devices (domestic/commercial) Mobile Refrigeration Mobile air conditioning gas devices Industrial Refrigeration gas devices Industrial Air conditioning gas devices Other:... Postal Address: Date of Birth: Phone: Mobile Phone: Gas: R-290; R-1150; R-170; E-170; R-600; R-600a; R-1270 Fax: Email: APPROVED / REJECTED Employer: (if not a sole trader) Regional Inspector, Petroleum and Gas (as delegated) Date: / / Effective 23 July 2012 Do you wish to receive information relating to your occupation, including those from other organisations? Yes No
SECTION 2 DETAILS OF LICENCE APPLIED FOR: * Interim licences may be issued at the discretion of the Chief Inspector. * Interim licences will only be issued for a one year licence term only. ** The issue of a full licence is subject to attaining national competencies. ** The first full licence issued is for one year only with subsequent licences issued in yearly increments between 1 and 5 years. Licence type requested: Interim * Full ** Licence period requested: 1 Year 5 years Other: years (5 year maximum) SECTION 3 SCOPE OF WORK: The scope of work should detail what the licence will cover. This can be generic and wide reaching or restricted to a particular activity, a particular device, or part of a device. The scope must be commensurate with your skills and competencies. 3.1 Type of work: Installing Repairing Servicing Tick all areas which cover the proposed work. Removing Altering Certifying Testing 3.2 Type of gas devices: Detail type of device or part of devices that the licence will cover and provide other details as required. Stationary Refrigeration gas devices (domestic/commercial) Stationary Air conditioning gas devices (domestic/commercial) Mobile Refrigeration gas devices Mobile Air conditioning gas devices Industrial Refrigeration gas devices Industrial Air conditioning gas devices Other:.. 3.3 Type of gas Detail gas / gases to be used, as defined in AS1677 Part 1, Table 3.1 R-290 R-1150 E-170 R-1270 R-170 R-600 R-600a More Information: (Describe in simple terms work to be undertaken) SECTION 4 Prior to 2005, did you hold a Queensland Hydrocarbon Refrigerant licence OR from 2005, a Queensland Gas Work Authorisation (Hydrocarbon Refrigerants)? YES NO (If YES) Licence/Authorisation Number: Expiry / Cancellation Date:.... Do you hold or previously held an ARC licence? YES NO (If YES) Licence Number:.... Expiry / Cancellation Date:...
SECTION 5 DOCUMENTS TO BE SUBMITTED WITH THIS APPLICATION: (All required information should be submitted below or if insufficient space, a separate sheet may be used. Use the Gas Work Licence Notes 2011 Part 2 [Hydrocarbon Refrigerants] to assist you in completing this section.) 5.1 Competencies and Skills: Supplied in previous application Detail below and attach evidence of the knowledge, competencies and qualifications that the applicant has pertinent to the proposed scope of work. (Evidence may include licences, trade competency certificates and inhouse training records.) NOTE: Originals are not to be forwarded. You must provide copies certified by a Justice of the Peace or Commissioner of Declarations. Note, if any evidence of qualifications has already been supplied to obtain a previous authorisation/licence, it does not have to be resubmitted. General Refrigeration: Hydrocarbon Refrigeration: 5.2 Experience: Detail the gas work (and any related work such as refrigeration/air conditioning work) that the applicant has undertaken in the past three years. For reapplications, summarise work undertaken during the last licence period. This should include the type of gas devices, type of gas activities and their complexity. SECTION 6 THE FOLLOWING INFORMATION MUST ALSO BE LODGED. Originals are not to be forwarded. All copies must be certified by a Justice of the Peace or Commissioner of Declarations. Prescribed application and licence fees (all applications). *Copy of Completion of Apprenticeship (Refrigeration/air conditioning) as per Appendix K, Gas Work Licence Notes 2011. *Copy of Training Certificate undertaken by a gas device manufacturer (interim licence applications only). *Copy of ARC licence. *Copy of certificate of formal competency based training in the safe use of hydrocarbon refrigerants from an RTO (full licence applications only). *Copy of any other licence relevant to hydrocarbon refrigerant air conditioning and refrigeration work. *Proof of identity of the applicant. NOTE: * These items are not required to be lodged if supplied with a previous application.
SECTION 7 CERTIFICATION I, the undersigned, declare that a) The information and attachments provided in this application are true and correct in every way. b) I am aware of the requirements under the Petroleum and Gas (Production and Safety) Act 2004 and Regulation relating to Gas Work Licences (Hydrocarbon Refrigerants) and use of flammable hydrocarbon refrigerant gas, and have read the Gas Work Licence Notes 2011, Part 2, together with all other important notes detailed on this application form. c) I acknowledge that this licence only authorises the individual applicant to undertake relevant gas work. d) As a condition of my licence I will ensure that before I install/service any device, it complies with the requirements of Petroleum and Gas (Production and Safety) Act 2004 and Regulation particularly s708a and compliance with relevant standards, s115a of the Regulation, Schedule 8 of the Regulation and that it has been approved for use under s733(2) of the P&G Act. e) It is a condition of the licence that the holder will, when requested by an Inspector, provide copies of any gas system compliance certificates issued and details (including the location of any devices installed) of any gas work undertaken under the licence. f) If I surrender my licence, or if my licence is cancelled, I agree to immediately return all unused Gas System Compliance Certificates and Gas Work Licence to a Petroleum and Gas Inspectorate regional office listed below. g) It is a condition of this licence that the licence holder shall comply with AS1677:2 1998 Refrigerating systems, Safety requirements for fixed applications when installing, maintaining or servicing a relevant appliance in particular section 4, 5, 6 and Appendix D, E & G. h) It is a condition of this licence that the licence holder advise the owner/operator of any installed system of their obligations in AS1677:2 1998 Refrigerating systems, Safety requirements for fixed applications when operating a relevant appliance, in particular section 6 and Appendix F. i) I will abide by the terms and conditions of the licence, if granted. Signature: Date: FEES The following fees must accompany First and Subsequent applications. Cheques are to be made payable to the Department of Natural Resources and Mines. Credit card payment details are to be completed on the Credit Card Payment Request Form (included with this application form). Application Fee (non-refundable) $ 37.50 plus Interim Licence Fee (One year) $ 25.00 (Total payable = $ 62.50) or Full Licence Fee (One year) (1 st Full issue) $ 25.00 (Total payable = $ 62.50) or Full Licence Fee (Five years) $125.00 (Total payable = $162.50) SEND APPLICATION TO: Operations Support Officer Petroleum and Gas Inspectorate Department of Natural Resources and Mines Level 5, QIDC Building 34 East Street (PO Box 548) ROCKKHAMPTON QLD 4700 Phone: (07) 4938 4683 FURTHER INFORMATION: Regional Inspector, Petroleum and Gas Central Region Department of Natural Resources and Mines Level 5, QIDC Building 34 East Street (PO Box 548) ROCKKHAMPTON QLD 4700 Phone: (07) 4938 4682 Email: gassafe@deedi.qld.gov.au Website: www.deedi.qld.gov.au GENERAL PRIVACY STATEMENT The Queensland Government introduced Information Standard 42 Information Privacy to ensure that the collection, use, disclosure and storage of personal information by government agencies are lawful and appropriate. This standard also obliges agencies to tell their clients why personal information is being collected and when it is being disclosed to third parties. The Department of Natural Resources and Mines collects the information on this form under the Petroleum and Gas (Production and Safety) Act 2004 (The Act) to meet its obligations under the Petroleum and Gas (Production and Safety) Act 2004 (the Act) and Regulation, and to facilitate and regulate the carrying out of responsible petroleum and gas activities and the development of a safe, efficient and viable petroleum, fuel gas and coal industries in Queensland. Information collected on this form may be disclosed to others where such disclosure is necessary for the effective management of gas licensing in Queensland. Your personal information will not be disclosed to any other third party without your consent, unless required by law, or for the purpose of Information Standard 42. For more information on Information Privacy, please contact the Privacy Contact Officer on (07) 3404 8272.
Credit Card Payment Request LICENCE HOLDER DETAILS Name: Address: State: Telephone: ( ) Fax: ( ) DESCRIPTION Gas Work Licence fees (1 year) Gas Work Licence fees (5 years) Other (specify) TOTAL $ PAYMENT DETAILS Payment Type: Mastercard Visa (Please Tick) Amount of Payment $ Expiry Date.. /.. Card Number Cardholder s Name.. Phone No...... Cardholders Signature.. Date.. / /. OFFICE USE Received By: Post At counter Received By Date (Name) ONLY Receipt No. Privacy Notice The Department of Natural Resources and Mines is collecting the information on this form to charge your credit card for one of the purposes identified in the description section of this form. Only authorised departmental officers have access to this information and your information may be disclosed to your nominated financial institution for the purposes of processing this transaction. Your personal information will not be disclosed to any other third party without your consent, unless required to do so by law or for the purposes of the Information Privacy Act 2009.