Controlled Substance Licence Application Form



Note for Applicants

The Controlled Substance Licence (CSL) can only be issued if the applicant has an Approved Handler Certificate (AHC) for the substances required. Pilots may use their Chemical Rating Certificate instead. The AHC is obtained through a test certifier. Before you start the application process, talk to a test certifier.

A list of test certifiers is available at . An application guide is also available on our website t.nz

Complete in your own handwriting. Please print clearly. Ensure the whole form is completed and attach all necessary extra documents.

The standard processing time for applications is 20 working days after receipt of all necessary information. If the application is incomplete it will not be accepted by WorkSafe New Zealand and we will return it to you for completion.

|TEST CERTIFIER USE ONLY |

| Correct licence requirements completed |Work requirement: |

| Applicant aware of any ACVM requirements for VTAs | Work need verified by Test Certifier |

| Approved Handler Certificate sighted, copy attached | Applicant aged 17 years or over |

|Evidence of Identity provided for new applications: | |

| Original documents sighted & returned | Declarations signed by applicant (& referee if required) |

| Verified copy of 3 identity documents attached |Application sent to WorkSafe New Zealand on / / |

| Photos provided (one signed by trusted referee) |(WorkSafe New Zealand, PO Box 165 WELLINGTON 6140 ) |

| Trusted referee meets criteria | Test Certifier records updated |

| | |

|Test Certifier name Test Certifier number |Test Certifier signature Date |

|Applicant Details |

|Name |

|This should be your full name as recorded on your birth certificate, unless your name has been legally changed; in which case, please state the name as|

|specified on the Name Change Certificate. Include any other name used now or in the past and reasons for this. |

|Surname/Family name | |

|First name | |

|Middle name(s) | |

|Other names used | |

|Reason for other name | |

Tick here if you have attached additional information or Name Change Certificate.

|Address |

|The CSL will be sent to your postal address. These details are required if we need to contact you about your application. If you change your address |

|after you have been issued with a CSL please advise WorkSafe New Zealand so that we are still able to contact you. |

|Applicant’s postal address: |

|Applicant’s residential address: |

|Mobile number: |Work number: |

|Home number: |Email: |

|Age and Gender |

|You must be 17 years of age or over to apply for a Licence. |

|Date of Birth |Gender Female Male |

|Place of Birth | |

|NZ Driver’s Licence |

|Please include your Drivers Licence details if you have one. |

|NZ Driver’s Licence Number: |Expiry date: |

|Evidence of Identity |

|For Replacement of an existing CSL |

|This section applies to people who have previously held a Controlled Substance Licence. |

|If you do not have a CSL then you must complete Section 2.2 and provide a completed Trusted Referee Statement (see Section 2.3). |

I already have a Controlled Substance Licence (CSL).

My CSL number is: CSL Expiry Date:

New photos are also required if you are renewing or replacing an expired CSL. They do not need to be signed.

Go to Section 3.

|Identity Documents for a new CSL |

|You must provide certified copies of one primary and two secondary documents. |

|At least one of these should be a photographic identity document and one should show your current address. |

|The documents can be certified by the test certifier or can be verified by the issuing authority or a Justice of the Peace, Registrar or court |

|official. |

|Documents must be valid. Passports will be considered valid up to 6 months after expiry. |

|IRD, Electoral Roll, Utility or Bank Account documents must be less than one year old. |

|The documents should show the name that will be recorded on your CSL, unless you provide supporting evidence for another name. |

You must enclose a copy of one of the following primary documents: (tick those you have supplied)

| New Zealand or Australian Passport | New Zealand Citizenship Certificate |

| New Zealand full Birth Certificate | New Zealand Certificate of Identity |

| New Zealand Firearms Licence | Overseas Passport (with New Zealand Immigration Visa/ Permit) |

You must also enclose a copy of two of the following secondary documents: (tick those you have supplied)

| NZ Driver’s Licence or International Driving Certificate | Electoral Roll Confirmation of Enrolment Letter |

| | Photo ID (Student ID, HANZ 18+ID, Employee ID, or similar) |

| IRD Statement | Utility Account Bill (Power, Gas or Telephone) |

| Community Services Card | Bank Statement |

|Trusted Referee |

|Your Trusted Referee must complete the Trusted Referee Statement (Appendix 1): see the Applicant Guide. |

| Trusted Referee Statement (Appendix 1 of this form) completed and attached |

| 2 passport quality photographs attached | One photograph is signed by my Trusted Referee |

|Substances Required |

|Substances Required |

|This section should be completed in discussion with a test certifier. Tick only the substance(s) needed. Please note that: |

|a CSL can only be issued for those substances named on your Approved Handler Certificate (AHC) except pindone as pre-mixed baits; |

|to add substances to an existing CSL – tick all substances required. |

Vertebrate Toxic Agents

| 3-chloro-p-toluidine hydrochloride (DRC1339) | sodium fluoroacetate (1080) |

| potassium cyanide | para-aminopropiophenone (PAPP) |

| sodium cyanide | pindone |

| yellow phosphorus | microencapsulated zinc phosphide (MZP) |

Fumigants

| 1,3-dichloropropene | phosphine |

| 1,3-dichloropropene & chloropicrin | aluminium phosphide |

| chloropicrin | magnesium phosphide |

| hydrocyanic acid | methyl iodide & chloropicrin |

| methyl bromide | |

Explosives

|Classes |Industry type |

| 1.1 A | 1.3C | Mining - metalliferous | Quarrying |

| 1.1B | 1.3G | Mining - coal | Research |

| 1.1C | 1.4A | Surface mining | Propellants |

| 1.1D | 1.4B | Tunnelling | Transport |

| 1.1D Type A | 1.4C | Land operations | Snow avalanche control |

| 1.1D Type B | 1.4D | Construction | Seismic surveys |

| 1.1D Type D | 1.4E | Demolition | Oil & Gas industry |

| 1.1D Type E | 1.4G | Pyrotechnics | Underwater |

| 1.1G | 1.4S | Pyrotechnics – special effects | Wholesaler/ Warehousing |

| 1.2C | 1.5D | Other (please describe):       |

| 1.2G | 1.5D type E | |

| Class 1 | | |

|Approved Handler Certificate |

|The expiry date of your CSL will match the expiry date of your current Approved Handler Certificate (AHC). |

|Pilots can use a valid Chemical Rating Certificate (CRC) if they wish to do aerial application only. In this case, they must provide a copy of their CRC |

|instead. The CSL will match the expiry date of the CRC. |

|Certificate Number: |Expiry date: |

Verified copy of Approved Handler Certificate attached or (Pilots only) Verified copy of Chemical Rating Certificate attached

|Verification of work need |

|Verification of work need |

|Work need is verified either by the test certifier or by a Statutory Declaration (Appendix 2). |

|Letters from employers may be used as supplementary evidence. |

|Self employed workers must use a Statutory Declaration, which is witnessed by an authorised person (see applicant guide). |

Statutory Declaration signed and attached or Test Certifier verification:

I verify that I am satisfied that the applicant requires possession of the substances listed in Section 3 as part of their work for the following purposes:

| |

| |

| | |

|Test certifier’s name |Signature |Date |

|Fit and Proper Person Assessment |

|Behavioural History |

|You must be a fit and proper person to have a Controlled Substance Licence. See applicant guide for more information. |

Read through each of the following statements carefully and tick the box if it applies to you. If there is any box that you cannot tick please provide further information on why you should still be considered for a CSL.

Details on further information required are contained in the Guidelines for Granting Controlled Licences.

| I do not have any pending criminal proceedings against me, whether in New Zealand or elsewhere; |

| I have not had any court convictions in the last seven years or court orders made against me in New Zealand or elsewhere; |

| I have not been convicted of drink-driving in the last 7 years; |

| I have never been sentenced to a custodial sentence e.g. imprisonment, corrective training, home detention; |

| I have never had a protection order or orders (including a temporary protection order) made against me; |

| I have not had four or more infringement notices issued against me in the last two years (such as for traffic offences); |

| I do not have a history of violence (whether or not I have been convicted of any violent offence); |

| I do not have a history of drug or alcohol abuse (whether or not I have been convicted of a drug or alcohol-related offence); |

|Declaration |

|I |

|[Your full name] |

| |of |

|[Occupation] |[City, town or district where you live] |

declare that the information I have supplied for this application form is true, complete, and correct, and in my own handwriting.

I acknowledge that a Controlled Substance Licence (CSL) can be suspended or revoked if the CSL is obtained by false or misleading information (or for the other reasons specified in regulations 6D and 6E of the Hazardous Substances and New Organisms (Personnel Qualifications) Regulations 2001).

I understand that the information I have provided on this form and on any accompanying document, or information which is obtained from other sources, is my personal information and, collected for the purpose of assisting WorkSafe New Zealand to determine my identity and eligibility for a CSL in accordance with the Hazardous Substances and New Organisms (HSNO) Act 1996 and as a condition of registration under the Agricultural Compounds and Veterinary Medicines (ACVM) Act 1997.

I acknowledge that my personal information will be processed and held by WorkSafe New Zealand, PO Box 165, Wellington 6140, and that under the Privacy Act 1993 I am entitled to access my personal information and to ask for correction should that be necessary.

Disclosure of my personal information

I authorise WorkSafe New Zealand to disclose my personal information to:

• any person, including government agencies such as the NZ Police, for the purpose of issuing, suspending or revoking any CSL which may be issued to me;

• any HSNO Enforcement Agency as defined by section 97 of the HSNO Act for the purpose of administering the provisions of the HSNO Act;

• the Ministry for Primary Industries for the purpose of enforcing the provisions of the ACVM Act 1997; and

• any government agency whose legislation requires that the personal information WorkSafe New Zealand holds is released to them. For example: Inland Revenue and NZ Police.

Verification of my personal information

I authorise:

• WorkSafe New Zealand to make inquiries into my fitness to hold a CSL and to verify any of my personal information held by WorkSafe New Zealand with the relevant agency or individual concerned (including where relevant any overseas agency or individual), both before and after a CSL has been issued to me;

• the relevant agency or individual concerned to disclose any information that the agency or individual holds about me that is relevant to the issuing, suspending or revoking of any CSL which may be issued to me.

For the avoidance of doubt, I authorise the NZ Police to disclose to WorkSafe New Zealand, any information held by Police, including any interaction I have had with Police in any context or any information received by Police.  I understand that this is not limited to conviction information.

| | | | |

|Applicant’s signature |Date |In the Presence of (witnessed by) |Date |

This application must be received by WorkSafe New Zealand within three months of being signed.

|Appendix 1 – Trusted Referee Statement |

To the Applicant: If you are providing a New Zealand or Australian Passport or a New Zealand Firearms Licence as a primary identity document, then a Trusted Referee statement is not needed.

To the Trusted Referee: You have been asked to act as a referee for a person applying for a licence to possess controlled substances.

If you cannot provide all the information required below or do not meet the requirements then you should not act as the referee.

You must:

• be over 17 years of age;

• have known the applicant for at least 12 months;

• not be a relative or partner or spouse of the applicant, nor living with the applicant;

• be someone “of standing” and trust within the community (as listed below).

|Trusted Referee Details |

|Given/First names: |

|Surname/Family name: |

|Address: |

| |

|Phone number you can be contacted on: |

|Email address: |

Which of these are you?

| practising lawyer | justice of the peace | police officer |

| test certifier | applicant’s employer | registered teacher |

| minister of religion | senior government official | registered accountant |

| elected official | kaumatua | registered medical professional |

| CSL holder | firearms licence holder | |

|How long have you known the applicant? |

|How do you know the applicant? |

| |

| |

I have signed the back of one of the photographs as shown.

|Trusted Referee Declaration |

|I |

|[Your (the Trusted Referee’s) full name] |

| |of |

|[Occupation] |[City, town or district where you live] |

declare that:

• I am over 17 years of age;

• I have known the applicant for at least 12 months;

• I am not a relative, spouse or partner of the applicant, nor am I living with the applicant;

• the information I have supplied in this Trusted Referee Statement, is true and correct and is in my own handwriting;

• the photograph I have witnessed is of the applicant named in the application form Section 2 – Applicant’s Details;

I consent to WorkSafe New Zealand verifying any of the information provided by me, both before and after a Licence has been issued to the applicant with any relevant agencies or individuals (including, where relevant, any overseas agency or individual). I authorise:

• WorkSafe New Zealand to disclose any information about me to any person, for the purpose of issuing, suspending or revoking the applicant’s licence;

• the relevant agency or individual concerned to disclose any information that the agency or individual holds about me that is relevant to the issuing, suspending or revoking of the applicant’s licence.

| | |

|Trusted Referee’s signature |Date |

|Appendix 2 – Statutory declaration of work need |

| I, |

|[Your full name] |

| |of |

|[Occupation] |[City, town or district where you live] |

solemnly and sincerely declare that being the applicant for a Controlled Substance Licence under section 95B of the HSNO Act, I require possession of the hazardous substances listed in Section 3 (substances required) of the attached application for a Controlled Substance Licence in my name, for the purposes of my work as

| |

| |

|[State the work you do and why you need the substances] |

I declare that the statements made in this application are, to the best of my knowledge, true, complete and correct.

I understand that if I have provided false information my Controlled Substance Licence can be revoked or suspended and I can, by law, be fined or imprisoned.

And I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act 1957.

| |

|Signature of applicant |

|Declared at |this |day of |20 |

| |[Place where you are making declaration] | [day] |[month] |[year] |

before me:

| |

|Signature |

| | |

|[Name] Barrister or Solicitor of the High Court of New Zealand or Justice of the Peace, Notary Public, Registrar or Deputy Registrar of a New Zealand|

|Court. |

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