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Getting Started

Application to vary or transfer a management licence

Fields marked with * are required

Do you need to complete this form?

Variation to your existing management licence:You must apply to vary your existing management licence if you intend to change the scope of your practice, such as the number or types of radiation sources involved. The application must be approved by the Department before the proposed changes occur. For example, a radiology practice may wish to:•Expand by setting up a radiology practice with X-ray units at a new location•Acquire a different type of radiation source (e.g. a CT scanner) at an existing authorised location•Acquire an additional X-ray unit of the same type as they already are authorised to possess at an existing authorised location•Move from their current authorised location to another location.It is an offence against the Radiation Act for a management licence holder to take possession of a new radiation source before that activity has been authorised in their licence.Transfer a management licence into your name:You may apply to have an existing management licence transferred to your name or your company name. The application to transfer the management licence must be approved and a licence issued prior to you taking control of the licensed practice.Written consent from the existing management licence holder must be included in the application to transfer.A transfer can only be undertaken if you as the new owner do not already have a management licence. If you do have a pre-existing management licence for another radiation practice, use this form to vary your existing management licence.Information about the anticipated processing time for applications can be found on our website.

What are you applying for?

Variation to my existing management licence

Transfer of a management licence into my name

Management licence number to transfer to your name *

Management licence number to vary *

As shown on your management licence.

Applicant details

Application to vary or transfer a management licence

Fields marked with * are required

Applicant details

Is the applicant a company or individual?

Company

Individual

Company details

Details (NB: Must be a legal entity such as a company incorporated under the Corporations Act or a legal entity established under some other legislation. A trust or a trustee of a trust or a registered business name that is not also a separate legal entity will not be accepted. Refer to https://www.health.vic.gov.au/radiation/sector-specific-information-for-management-licences for further information)

ACN

ABN

Company name

Business or trading name

Applicant name

Title

Surname

Given name

ABN

Business address

Note: A full and correct physical address is required. No postal address will be accepted.

Country *

Address Line 1 *

Address Line 2

Suburb *

State *

Postcode *

Address Line 1 *

Address Line 2

Suburb *

State

Postcode

Mailing address

Same as business address

Country *

Address Line 1 *

Address Line 2

Suburb *

State *

Postcode *

Address Line 1 *

Address Line 2

Suburb *

State

Postcode

Contact person details

Name of person authorised by licence holder to act on licence holder’s behalf.

The person completing this form must be a contact person who has been authorised by the licence holder to act on the licence holder’s behalf for the purpose of the requirements under the Radiation Act 2005. Are you authorised by the licence holder to act on their behalf in relation to all radiation safety requirements (Radiation Act 2005)?

Yes

Have you previously submitted proof of authorisation to the Department as specified in the sector-specific information for management licences found at https://www.health.vic.gov.au/radiation/sector-specific-information-for-management-licences?

Yes

Note : Please attach the document specified in the sector-specific information for management licences found at https://www.health.vic.gov.au/radiation/sector-specific-information-for-management-licences

Note: Only authorised persons may complete this form. For further information please refer to the sector-specific information for management licences found at https://www.health.vic.gov.au/radiation/sector-specific-information-for-management-licences

Contact person details

Title *

Surname *

Given name *

At least one contact phone number is required *

Business phone

Mobile

Fax

Business email *

All correspondence will be sent to the email address listed above.

Variation details

Application to vary or transfer a management licence

Fields marked with * are required

Radiation practice details

Site

Please list the details of the site where you wish to conduct the radiation practice.Note: A full and correct physical address is required. No postal addresses will be accepted.

Same as business address

Building name

Site name *

Address Line 1 *

Address Line 2

Suburb *

State *

Postcode *

Site telephone *

Is this site already listed on your licence?

Yes

Variation

You now need to tell us about each and every change to the radiation sources you wish to be authorised to possess at this site.

What changes do you want to make to your licence?

Possess more radiation sources

Conduct a radiation practice other than possession
e.g. Sell radiation sources, transport radioactive material or conduct research involving irradiation of persons.

Reduce what I'm authorised to possess on my licence
This is not used to dispose of a radiation source

Other

Are you removing all radiation sources you are authorised to possess at the current site?

Yes

Radiation practice details - Possess More

Select the sector which best describes the site *

Purpose *

Type of radiation source *

Proposed location of the source within the site *

Radionuclide *

Maximum activity *

Unit *

Proposed location of the source within the site *

Radionuclide *

Maximum activity *

Unit *

Radiation practice details - Conduct

Select the sector which best describes the site *

Purpose *

Type of radiation source *

Radionuclide *

Maximum activity *

Unit *

Radionuclide *

Maximum activity *

Unit *

Detailed description of the radioactive materials that are proposed to be transported *

Radiation practice details - Reduce

Select the sector which best describes the site *

Purpose *

Type of radiation source *

Authorisation number *

Radionuclide *

Maximum activity *

Unit *

Radionuclide *

Maximum activity *

Unit *

Please specify *

To add another Site, click the Add site button

Confirmation

Application to vary or transfer a management licence

Fields marked with * are required

Confirmation

Please confirm the following is correct. Please select 'Add' or 'Remove' buttons above if not correct.

Supporting documents

You will be asked to provide the supporting documents when you submit this form.For details on information and documentation you are required to attach with your application, please refer to sector specific information at the following website: https://www.health.vic.gov.au/radiation/sector-specific-information-for-management-licencesIf you fail to provide the requested information your application may be returned resulting in unnecessary processing delays.

I acknowledge my form will be returned if I do not include supporting documentation *

Licence duration

1 year

2 years

3 years

Information about fees is on the Department website.

Payment details

DO NOT SEND IN PAYMENT - You will be sent a request for payment once your application has been assessed.Please note that a licence cannot be issued until the prescribed fee has been received by the Department and your application has been fully assessed. You will be advised of the decision and, subject to the approval of your application, you will be sent a licence.

Additional information

Is there anything you would like to tell us?

Acknowledgement

I understand and acknowledge that: •The information provided in this application is true and complete to the best of my knowledge.•The Department of Health may refuse this application if it becomes evident that information or any supporting documentation provided is incomplete or false.•This application forms a legal document and penalties exist for providing false or misleading information.

By ticking this checkbox I confirm that I have read and understood all the statements above *

Full name of the person completing this application *

Date *

Privacy statement

The Department of Health is bound by Victoria's privacy laws, including the Information Privacy Act 2000. The Radiation Act 2005 provides that an application for a management licence must include certain information, including information about the radiation sources or kinds of radiation sources in relation to which the applicant will conduct a radiation practice. We will use the personal information provided by you on this form to assess your application for a management licence and to monitor your compliance with the Act. If you do not provide us with this information, we may not be able to assess your application. It is an offence for you to possess a radiation source unless you hold a current management licence that allows the possession of that source.You have the right under FOI legislation to apply for access to, and correction of, your personal information held by the Department. For more information about how to make a request, please visit the Department of Health's FOI website at https://www.health.vic.gov.au/freedom-of-information or call 1300 020 360.Section 136 of the Radiation Act allows the Department to disclose information that it collects under the Radiation Act or the Radiation Regulations 2007 to certain persons and agencies (including the Health Services Commissioner, the Victorian Workcover Authority, the Commonwealth Health Insurance Commission and some practitioner registration boards) for the purpose of performing its statutory functions or to assist other government bodies to perform their functions.

Lodgement

If you are having difficulty completing of submitting this form, please contact:Department of Health
Registration and Licensing
GPO Box 4541
Melbourne VIC 3001Telephone: 1300 767 469
Email: radiation.safety@health.vic.gov.au
Website: https://www.health.vic.gov.au/public-health/radiation

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Our Website

Getting Started

Applicant details

Applicant details

Company details

Applicant name

Business address

Mailing address

Contact person details

Contact person details

Variation details

Radiation practice details

Site

Variation

Radiation practice details - Possess More

Radiation practice details - Conduct

Radiation practice details - Reduce

Confirmation

Confirmation

Supporting documents

Licence duration

Payment details

Additional information

Acknowledgement

Privacy statement

Lodgement