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 16(1) of the Nuclear Non-Proliferation (Safeguards) Act 1987, to transport the nuclear material described below, being nuclear material 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 nuclear material, including physical form, chemical and isotopic composition, weight and quantity, and any identification markings	(see Instruction 2)
	
(E)	List each type of nuclear material to be held, and the maximum quantity of each one in your possession at any one time?  (see Instruction 3)
	
(F)	Who is/will be the consignor(s) and consignee(s) of the nuclear material?
Consignor(s)		Consignee(s)	

	

Permit number:				Permit number:			

	

Permit number:				Permit number:			

	

Permit number:				Permit number:			
			
(G)	Locations involved?
Pick-up address(es)		Destination address(es)	

			

			
			
(H)	What means of transportation will be used, and what is the transport route? Provide a map showing the route. (see Instruction 4)
	
(I)	What measures will be taken to prevent theft, loss or unauthorised use of the nuclear material (provide diagrams or photographs where necessary)? (see Instruction 4)
	
(J)	What procedures will be implemented to generate accurate records for all nuclear material receipts and despatches (eg, Register of Movements)?
	
(K)	Is this application for a permit related to a single transportation event, repeat events or multiple events? (see Instruction 5)
Single event		Indicate dates or time period:		
Repeat event(s)		Provide details:	

Multiple events		Provide details:	

	
(L)	Is there any other relevant information?
	
(M)	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:		
(N)	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 (N). 
2.	Nuclear material means any source or any special fissionable material as defined below (see the Nuclear Non-Proliferation (Safeguards) Act 1987, and Article XX of the Statute of the International Atomic Energy Agency):
(a)	The term "special fissionable material" means plutonium-239; uranium- 233; uranium enriched in the isotopes 235 or 233; any material containing one or more of the foregoing; but the term "special fissionable material" does not include source material.
(b)	The term "uranium enriched in the isotopes 235 or 233" means uranium containing the isotopes 235 or 233 or both in an amount such that the abundance ratio of the sum of these isotopes to the isotope 238 is greater than the ratio of the isotope 235 to the isotope 238 occurring in nature.
(c)	The term "source material" means uranium containing the mixture of isotopes occurring in nature; uranium depleted in the isotope 235; thorium; any of the foregoing in the form of metal, alloy, chemical compound, or concentrate.
3.	Use the following bracketed letter(s) to indicate the category(s) of nuclear material to be held, and the total quantities for each one:
(D)epleted uranium, (N)atural uranium, (E)nriched uranium, (P)lutonium and (T)horium
4.	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.
5.	‘Repeat events’ means those events that have the same pick-up and delivery address.  ‘Multiple events’ means any number of pick-up locations, with any number of possible destinations, and in no particular order of pick-up and delivery.
6.	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