TO:	The Director General,
	Australian Safeguards and Non-Proliferation Office

	The following application is hereby made for the granting of a permit under sub‑section 13(1) of the Nuclear Non-Proliferation (Safeguards) Act 1987, to possess the associated item(s) described below, being associated item(s) to which Part II of that Act applies.

– PLEASE READ THE INSTRUCTIONS ON THE LAST PAGE –

(A)	What is the name of the applicant? (see Instruction 1)
		
	ABN / ACN:			
		
(B)	Provide a short description of the business or activity of the applicant
	
(C)	What are the applicant’s contact details?
Street Address	Postal address	
		
Phone:	(	)		Fax:	(	)		
Email address:		
(D)	Provide a description of the associated item(s), including any identification or markings	(see Instruction 2)

(E)	List each associated item(s) to be held, including any markings/identifications? 
(see Instruction 3)
	
(F)	Who is/will be the supplier(s) of the associated item(s)?
	
(G)	List all locations where the associated item(s) will be stored or used.
	
(H)	What procedure will be used to transport the associated item(s) from one location to another?
	
(I)	What measures will be taken to prevent theft, loss or unauthorised use of the associated item(s) (provide diagrams or photographs where necessary)? (see Instruction 4)
	
(J)	What are the name(s)—and position(s)—of the person(s) given responsibility for protecting the associated item(s) from theft, loss or unauthorised use?
NAME	POSITION	

		
		
(K)	What are the name(s) of the person(s)—or class of person(s)—who will be/have been granted access to the associated item(s)?
NAME	POSITION	

		

(L)	What procedural and/or physical restrictions will be applied to accessing the associated item(s)?
	
(M)	What procedures will be implemented to generate accurate accounting records for the associated item(s)?
	
(N)	What is the intended use(s) of the associated item(s)?
	
(O)	Will the associated item(s) be consumed (for associated material), or otherwise destroyed, and if so, how? 
	
(P)	Is there any other relevant information?
	
(Q)	What is the name, address and telephone number of the person authorised by the applicant to provide additional information in relation to this application?
Street Address	Postal address	
		
Phone:	(	)		Fax:	(	)		
Email address:		

(R)	SIGNED BY, OR ON BEHALF OF, THE APPLICANT:
** The signatory below must have organisational authority to represent the applicant and to implement the conditions of the permit when granted **
	
Name :			
	
Position:			
	    Signature:	_____________________________________	Date:	____/____/________	

INSTRUCTIONS

1.	If the application is being made by, or on behalf of, a corporation, organisation or legal entity, the name of the corporation, organisation or legal entity is to be inserted at question (A).  Do not insert the name of the person signing the application; this must happen at question (R). 
2.	Associated item(s) means any of the following:
(a)	Associated equipment means equipment or plant that:
(i)	is specially designed, manufactured or built for use, or is specially suited (whether with or without modification or adaptation) for use, in:
(A)	nuclear activities; or
(B)	the production of nuclear weapons or other nuclear explosive devices; and
(ii)	is included in a class of equipment or plant that is declared by the Minister, in writing, to be associated equipment for the purposes of this definition;
The above also includes a component or part of such equipment or plant.
(b)	Associated material means any material (other than nuclear material, associated equipment or associated technology) that:
(i)	is of a kind specially suited for use in nuclear activities, the construction of a nuclear reactor or the production of nuclear weapons or other nuclear explosive devices; and
(ii)	is included in a class of material that is declared by the Minister, in writing, to be associated material for the purposes of this definition.
(c)	Associated technology means any document that contains information (other than information that is lawfully available, whether within Australia or outside Australia and whether for a price or free of charge, to the public or a section of the public):
(i)	that is applicable primarily to the design, production, operation, testing or use of:
(A)	equipment or plant for:
•	the enrichment of nuclear material;
•	the reprocessing of irradiated nuclear material; or
•	the production of heavy water; or
(B)	nuclear weapons or other nuclear explosive devices; or
(ii)		to which a prescribed international agreement applies and that is of a kind declared by the Minister, in writing, to be information to which this definition applies;
The above also includes any photograph, model or other thing from which such information may be obtained or deduced.
3.	Where there is insufficient space on this form to furnish complete information, additional information must be provided on separate sheets, numbered consecutively and signed by, or on behalf of, the applicant.
4.	To expedite the application process, the applicant may send information electronically in the first instance, and then post the originals, noting that the application cannot be completed until the original posted documents are received by ASNO. ASNO’s contact details are:
Phone:	(02) 6261 1920
Facsimile:	(02) 6261 1908
Email:	nuclear.asno@dfat.gov.au
Postal address:	The Director General
	Australian Safeguards and Non-Proliferation Office
	R.G. Casey Building
	John McEwen Crescent
	Barton ACT 0221