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 18(1) of the Nuclear Non-Proliferation (Safeguards) Act 1987, to communicate the information described below, being information 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)	Do you currently have, or have you made application for, a Permit to Possess an Associated Item?  (see Instruction 2)
	
Yes, I have a permit		My permit number is PA			
	
No, I do not have a permit		but I have applied for one. 	Date of mailing =			
	
No, I have not applied for a permit yet		
	
(C)	Provide a short description of the business or activity of the applicant
	
(D)	What are the applicant’s contact details?
Street Address	Postal address	
		
Phone:	(	)		Fax:	(	)		
Email address:		
(E)	Provide a description of the information
	
(F)	What are the name(s) of the person(s)—or the class of persons—to whom the information will be communicated.
Name	Position	

		
		
(G)	How will the information be communicated?
	
(H)	What is the reason(s) for the communication(s)
	
(I)	Is this application for an authority related to a single event, or for multiple events? (see Instruction 4)
Single event		Indicate dates or time period:		
Multiple event(s)		Provide details:		

(J)	Is there any other relevant information?
	
(K)	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:		
(L)	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 (L). 
2.	Possession of associated technology, which is a category of an “associated item”, requires a permit to be granted under sub-section 13(1) of the Nuclear Non-Proliferation (Safeguards) Act 1987.  The number of the applicant’s permit to posses the associated technology—containing the relevant information—should be inserted at question (B).
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.	‘Multiple events’ means any number of communications.
5.	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