APPLICATION FORM
CONTROLLED SUBSTANCE LICENCE
This form is for New and Renewing applications and Extensions to the Controlled Substance
Licence
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 http://www.epa.govt.nz/search-databases/Pages/testcertifierssearch.aspx. An application guide is also available on our website www.worksafe.govt.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
Applicant aware of any ACVM requirements for VTAs
Approved Handler Certificate sighted, copy attached
Work requirement:
Work need verified by Test Certifier
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 name
Test Certifier number
/
/
Test Certifier records updated
Test Certifier signature
Date
www.worksafe.govt.nz
2
Application Form: CSL
1. Applicant Details
1.1.
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.
1.2.
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:
1.3.
Age and Gender
You must be 17 years of age or over to apply for a Licence.
Date of Birth
Gender
Female
Place of Birth
1.4.
NZ Driver’s Licence
Please include your Drivers Licence details if you have one.
NZ Driver’s Licence Number:
September 2014
Expiry date:
Male
3
Application Form: CSL
2. Evidence of Identity
2.1.
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.
2.2.
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
2.3.
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
September 2014
One photograph is signed by my Trusted Referee
4
Application Form: CSL
3.
Substances Required
3.1.
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
1,3-dichloropropene & chloropicrin
chloropicrin
hydrocyanic acid
methyl bromide
phosphine
aluminium phosphide
magnesium phosphide
methyl iodide & chloropicrin
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
1.2C
1.5D
Other (please describe):
1.2G
Wholesaler/ Warehousing
1.5D type
E
Class 1
3.2.
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.
September 2014
5
Application Form: CSL
Certificate Number:
Expiry date:
Verified copy of Approved Handler Certificate attached
or
(Pilots only) Verified copy of Chemical Rating
Certificate attached
4. Verification of work need
4.1.
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
5. Fit and Proper Person Assessment
5.1.
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;
September 2014
6
Application Form: CSL
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);
September 2014
7
Application Form: CSL
6. 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
Date
(witnessed by)
This application must be received by WorkSafe New Zealand within three months of being signed.
September 2014
8
Application Form: CSL
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
CSL holder
firearms licence holder
registered medical
professional
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.
Certified true likeness
of
(Full name of applicant)
Trusted Referee
signature
Date
September 2014
9
Application Form: CSL
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
September 2014
Date
10
Application Form: CSL
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
[Place where you are making declaration]
this
day of
[day]
20
[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.
September 2014
11
Application Form: CSL
September 2014