This form is used to apply for an exemption in accordance with Regulation 684, 686 and 688 of the Work
Health and Safety (National Uniform Legislation) Regulations.
Please see information sheet Guide for Applicants for Exemptions for assistance in completing this form available from the NT WorkSafe website.
NB: One category per application
General
Exemption from holding a high risk work licence
Exemption for a major hazard facility
Application for an exemption
Name of the individual or contact person for body corporate
Surname:
Given Name/s:
Date of Birth: (high risk work licence only)
Address:
Suburb:
Is your postal address the same as above?
(If no, complete below)
Postal Address:
Suburb:
Work Number:
Email Address:
State:
State:
Mobile Number:
Has an exemption been issued previously (if yes, provide details below):
Postcode:
Yes No
Postcode:
Yes No
Exemption number (if known):

Application for an exemption
The provision of the Work Health and Safety (WHS) Regulation for which an exemption is sought:
The person or class of persons to whom the exemption will apply:
The work or thing for which an exemption is sought (if applicable):
Details of the exceptional circumstances for which the exemption is required:
Site address that will be affected by the exemption (if applicable):
Any condition/s on the exemption:
Length of time for which the exemption is being sought: months
Details of consultation that has occurred in relation to the proposed exemption: years
Application for exemption (V2 – February 2015)
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Application for an exemption
A risk assessment that shows the risk associated with the thing is not significant if the exemption is granted
Checklist for general exemption
Application form is complete including a signature in the declaration.
If the proposed exemption relates to a thing, evidence that the risk associated with the thing, is not significant if the exemption is granted has been submitted.
Evidence that consultation in relation to the proposed exemption has been undertaken in accordance with
Divisions 1 and 2 of Part 5 of the WHS Act has been submitted.
Additional information required for a high risk work exemption
Copies of documentation evidencing that the person’s competencies exceed those required for the high risk work licence for which an exemption is sought
Documents that demonstrate that the plant used by the person/class of persons can be modified to reduce the risk associated with its operation
Checklist for exemption from high risk work licence
Application form is complete including a signature in the declaration.
Copies of documents showing successful completion of competencies exceeding those required for the grant of the high risk work licence has been submitted.
Documents that demonstrate that the plant used by the person or class of persons can be modified to reduce the risk associated with its operation has been submitted.
Documents required for an exemption for a major hazard facility or proposed major hazard facility
Documents that demonstrate that one or more of the Schedule 15 chemicals present or likely to be present will periodically exceed the threshold quantity because: they are in intermediate temporary storage; and are in container/s with a capacity of each container to contain no more than 500kg of the chemical
Documents that demonstrate that the operator of the facility is complying with WHS Act and Regulations, including Part 7.1
Evidence that the facility has processes and procedures in place to keep the quantity of Schedule 15 chemicals present or likely to be present below threshold quantity as often as practicable
Evidence that that operator of the facility has implemented control measures to minimise the risk of a major incident occurring
Checklist for exemption for a major hazard facility
Application form is complete including a signature in the declaration.
Documents that demonstrate that the Schedule 15 chemical/s present or likely to be present will periodically exceed the threshold quantity because they are in intermediate temporary storage and in containers with a capacity to contain no more than 500kg of the chemical has been submitted.
Documents that the operator of the facility is complying with the WHS Act and Regulations, including Part
7.1 has been submitted.
Documents that evidence processes and procedures are in place which will keep the quantity of the
Schedule 15 chemical/s present or likely to be present at or below the threshold quantity as often as practicable has been submitted.
Documents that evidence that that operator of the facility has implemented control measures to minimise the risk of a major incident occurring has been submitted.
Application for exemption (V2 – February 2015)
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Application for an exemption
The information in this application is true and correct to the best of my knowledge.
I agree to my details being published by the WHS Regulator.
Applicant name:
Yes No
Signature: Date:
The Department of Business complies with the Information Privacy Principles scheduled to the Information Act.
Incomplete applications cannot be processed and will be returned. Complete applications, together with all supporting documents can be lodged either by post, fax or email.
Submit completed forms to NT WorkSafe via:
Post: GPO Box 3200, DARWIN NT 0801
Fax: (08) 8999 5141 or Email: ntworksafe@nt.gov.au
For further information please contact NT WorkSafe on 1800 019 115 or go to www.worksafe.nt.gov.au
Application for exemption (V2 – February 2015)
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