FORM FM0911
Application for entry and presence in a Petroleum Safety Zone
Part 1 – Details of person making the application
Name:
Date:
Position:
Phone:
Postal Address:
Email address:
Organisation:
 (Name of titleholder or registered facility operator)
Being the:
Holder of title:
or registered operator of the facility:
Part 2 – Details of well(s), Structure(s) and/or Equipment
(what is being protected, use part A, B, or C)
Part 2A - Details of petroleum safety zone notice gazettal by NOPSEMA
NOPSEMA Reference:
(Post 1 January 2012)
(this reference can be found on the letter from NOPSEMA advising of a successful application)
A
OR Part 2B - Details of petroleum safety zone notice gazettal by a Designated Authority
Date of gazettal:
Which Gazette? (e.g. WA, Vic etc)
Gazette No:
OR Part 2C - Details of well(s), Structure(s) and/or Equipment t
(thought to be protected by a petroleum safety zone)
Part 3 – Timing
Equipment
Title area
Structure
Description
Well
Name
(Pre 1 January 2012)
Latitude
(deg:min:sec.sec)
Longitude
(deg:min:sec.sec)
(for what period is consent to enter and be present being sought)
Commencement date:
Termination date:
If N/A then until safety zone revoked
Part 4 – Scope
(vessels to for which consent is being sought)
Part 4A - Details of specific vessels
Name
(insert additional rows as required
Number
Port of Registry
Or Part 4B - Details of a class of vessels
All vessels under contract to:
(Name of organisation)
Part 5 – Declaration & Sign-off
person making application
The undersigned declares that systems are in place to manage the risks to the well, structure and/or equipment that may be posed by the entry and presence
of the vessel(s) in the petroleum safety zone.
Signed:
Date:
Name:
Revision: 1
Revision Date: 18 March 2014
Page 1 of 2
National Offshore Petroleum Safety and Environmental Management Authority
Reference: N-04800-FM0911
Objective ID: A197961
FORM FM0911
Application for entry and presence in a Petroleum Safety Zone
Instructions for use:
1
This form is intended for use by titleholders and operators of facilities to apply for consent for one or more vessels or classes of vessels to enter and be
present in an established petroleum safety zone.
2
Applicants should complete Parts 1 to 4 before signing Part 5.
3
The completed application form should be emailed to safetyzones@nopsema.gov.au.
Notes:
1
Petroleum safety zones are provided for in Part 6.6 of the Offshore Petroleum and Greenhouse Gas Storage Act 2006
2
From NOPSEMA Policy N-04800-0916 (4.3.1):
NOPSEMA shall only consider applications for consent for a vessel(s) to enter and be present in a petroleum safety zone made by the relevant titleholder
or operator (of the petroleum production facility as defined in OPGGSA Schedule 3 clause 4(1)(b)(i)) associated with the well(s), structure(s), and/or
equipment being protected by a petroleum safety zone.
Privacy Notice
NOPSEMA collects your personal information so that it can administer the OPGGSA and associated regulations. If you do not provide your personal information,
NOPSEMA may not be able to process your application.
NOPSEMA will not use or disclose your personal information for any other purpose without your consent, unless it is required or authorised by law, or relates to
NOPSEMA’s enforcement activities. Your personal information may be disclosed to the following organisations, entities or individuals:

individuals who make a request under the Freedom of Information Act 1982

the Australian National Audit Office and other privately-appointed auditors

other law enforcement bodies (for example, the police or the Coroner)

NOPSEMA’s legal advisors.
NOPSEMA may occasionally be required to disclose information to overseas recipients in order to discharge its functions or exercise its powers, or to perform its
necessary business activities.
Information about how you can access, or seek correction to, your personal information is contained in NOPSEMA’s APP Privacy Policy at
www.nopsema.gov.au/privacy. If you have an enquiry or a complaint about your privacy, please contact NOPSEMA’s Privacy Contact Officer on 08 6188 8700 or by
email at privacy@nopsema.gov.au.
Revision: 1
Revision Date: 18 March 2014
Page 2 of 2
National Offshore Petroleum Safety and Environmental Management Authority
Reference: N-04800-FM0911
Objective ID: A197961