IMPORTANT: Your personal information is protected by law, including the Privacy Act 1988. Important information
about the privacy of your personal information is contained in our Privacy Collection Notice, available at
www.nicnas.gov.au/privacy/app5. You should ensure that you read and understand the Privacy Collection Notice
before completing this form.
Rotterdam Convention on the Prior Informed
Consent Procedure For Certain Hazardous
Chemicals and Pesticides in International Trade
FORM AA/EXP-1
Annual Authorisation Application Form
Industrial Chemicals (Notification and Assessment) Act 1989
Industrial Chemicals (Notification and Assessment) Regulations 1990
This application should be submitted at the start of the Calendar year to obtain annual authorisation to export industrial chemicals or mixtures
containing industrial chemicals or mixtures containing industrial chemicals that are subject to the Prior Informed Consent Procedure (PIC).
Please send applications to:
NICNAS
Compliance and Reporting
GPO Box 58
Sydney NSW 2001
Or fax to: (02) 8577 8888
Enquiries: Freecall 1800 638 528
Please allow TEN working days for processing. Use BLOCK LETTERS.
Section 1:
Exporter’s details
Company / Individual Name:
Address:
Town / Suburb:
State:
Phone:
Postcode:
Fax:
Email:
NICNAS Registration Number (if applicable):
Please provide a forecast / best estimate of what exports of PIC listed chemicals your business will be undertaking over the coming
Calendar year. For multiple importers, please add further pages to this application as needed indicating the information specified
below.
Note: Annual Authorisation applies: 1. If the export destination country is Party to the Rotterdam Convention and has provided an
import response for subject chemical; or 2. If an export destination country is not a Party to the Rotterdam Convention and has not
provided an import response to subject chemical – For further information on PIC import responses: http://www.pic..int in all other
cases please contact NICNAS immediately.
Section 2:
Importer’s details
Company / Individual Name:
Address:
Town / Suburb:
Country:
State:
Phone:
Postcode:
Fax:
Email:
NICNAS Registration Number (if applicable):
Page 1 of 3
IMPORTANT: Your personal information is protected by law, including the Privacy Act 1988. Important information
about the privacy of your personal information is contained in our Privacy Collection Notice, available at
www.nicnas.gov.au/privacy/app5. You should ensure that you read and understand the Privacy Collection Notice
before completing this form.
Section 3:
Description of goods
This section relates to chemicals and mixtures containing chemicals, if any, which are subject to the Prior Informed Consent
Procedure under the industrial category (ie. Chemicals listed in Annex III of the Convention) referred to as a PIC chemical.
Name of the PIC Chemical:
Common name and trade name:
CAS registry no.:
Australian Harmonised Commodity Code (AHECC) Classification:
Intended use details (ie. use in importing country):
PIC chemical is contained in a mixture:
Yes / No
Industrial / Pesticide / both
Amount of PIC chemical in the mixture:
%
Description of the mixture:
If planning more exports, expected total quantity in a year (if known):
Section 4:
Importing country requirements
Applies only to situations where the importing country specifies conditions on imports.
Include a statement demonstrating the steps taken to ensure that the conditions specified by the importing country are met:
Please attach a current MSDS (material safety data sheet) and label (Article 13 of the Convention outlines the
information required to accompany export of PIC chemicals).
Please Note
The purpose of this form is to determine if annual export authorisation may be granted. Giving false or misleading
information is a serious offence. The information provided in this application may be provided to other agencies as
authorised or required by law.*Annual Authorisations will not be processed until a payment advice form is
received with full payment. Payment advice form can be found in the ‘Forms’ section of the website.
Section 6:
Declaration
I hereby apply for permission to export the chemical detailed in this application. I declare that the product/s will be used
in accordance with all restrictions and conditions as specified in any Export Authorisation that may be issued as a result
of this application. I declare that the information that I have provided is true and accurate to the best of my knowledge.
Signature:
Name (please print):
Phone:
Date:
Position*:
Fax:
* must be CEO or similar responsible officer of the exporter
Page 2 of 3
IMPORTANT: Your personal information is protected by law, including the Privacy Act 1988. Important information
about the privacy of your personal information is contained in our Privacy Collection Notice, available at
www.nicnas.gov.au/privacy/app5. You should ensure that you read and understand the Privacy Collection Notice
before completing this form.
(Office Use Only)
Receipt:
D@N Ref:
Authorisation:
Sent:
PIC-2 – Revised November 2006
Received:
Page 3 of 3