Please resolve the following issues before proceeding
Click on an issue to go directly to the related section of the form.
errors found:
warnings found:

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 locationAcquire a different type of radiation source (e.g. a CT scanner) at an existing authorised locationAcquire an additional X-ray unit of the same type as they already are authorised to possess at an existing authorised locationMove 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?
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 details

Applicant name

Business address

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

Mailing address

Contact person details

Name of person authorised by the applicant to speak to the department about the application.
Are you authorised by the proposed licence holder/applicant to act on their behalf in relation to all radiation safety requirements (Radiation Act 2005)?
Have you previously submitted proof of authorisation to the Department as specified in the 'What do I need to include with my application for a licence - management?'' document found at https://www2.health.vic.gov.au/public-health/radiation/licensing/radiation-management-licences/radiation-management-licence-application?
Note : Please attach the document specified in the `What do I need to include with my application for a licence - management?' document found at https://www2.health.vic.gov.au/public-health/radiation/licensing/radiation-management-licences/radiation-management-licence-application
Note: Only authorised persons may complete this form. For further information please refer to the document `What do I need to include with my application for a licence - management?' document found at https://www2.health.vic.gov.au/public-health/radiation/licensing/radiation-management-licences/radiation-management-licence-application

Contact person details

At least one contact phone number is required *
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.
Is this site already listed on your licence?

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

Radiation practice details - Possess More

Radiation practice details - Conduct

Radiation practice details - Reduce

To add another Site, click the Add site button

Confirmation

Application to vary or transfer a management licence
Fields marked with * are required

Confirmation

Supporting documents

You will be asked to provide the supporting documents when you submit this form.Please refer to the document titled "What do I need to include with my application for a licence - management?" found on the Department's website at https://www2.health.vic.gov.au/public-health/radiation/licensing/radiation-management-licences/radiation-management-licence-application for further details of the information that you are required to attach with your application. If you fail to provide the requested information your application may be returned resulting in unnecessary processing delays.

Licence duration

Licence duration
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

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 & Human Services 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.

Privacy statement

The Department of Health and Human Services 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 & Human Services' FOI website at https://www2.health.vic.gov.au/foi or call (03) 9606 8449.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 & Human Services
Registration and Licensing
GPO Box 4541
Melbourne VIC 3001
Telephone: 1300 767 469
Fax: 1300 769 274
Email: radiation.safety@dhhs.vic.gov.au
Website: http://www.health.vic.gov.au/radiation
Department of Health & Human Services