PMTL application - Version 2.0 28/06/22 Page 1 of 5
Queensland Health
APPLICATION FOR A PEST MANAGEMENT LICENCE
Sections 75 and 78 of the Medicines and Poisons Act 2019
Section 70 of the Medicines and Poisons (Pest Management Activities) Regulation 2021
Guide to completing this application
• This application form is to be used to apply for a pest management licence under the Medicines and Poisons
Act 2019 (MPA) and the Medicines ad Poisons (Pest Management Activities) Regulation 2021 (Pest
Regulation)
• Please print clearly and answer all questions in full. You will be advised if information is incomplete or additional
information is required. Incomplete applications will delay the application process.
• Photocopied documents including evidence of identity must bear the signature, name and occupation of an
authorised identifier (verified copy) i.e. signed by health or legal professionals, Public Health Unit officers,
government representatives, public servants, bank officers.
• This application form is to be used for new, amendment or renewal of a pest management licence. This form
should also be used for inter-state applicants under the Mutual Recognition (Queensland) Act 1992 and the Trans-
Tasman Mutual Recognition Act 1997 (Cwlth).
• Applicants should indicate all endorsements sought under their pest management licence, see section 3.
• Applicants must provide a verified copy of their qualifications for the endorsement/s sought. Refer to the
‘Departmental Standard – Competency requirements for licensed technicians undertaking pest management
activities with pesticides and fumigants for details of the competencies required.
• Applicants for high-risk or sensitive places, should refer to the factsheet High-risk or sensitive places fact sheet
(health.qld.gov.au)
• Applicants for a fumigation licence, should provide:
– Declaration of assessment for site environments; or
– Evidence that demonstrates competence and experience which include:
– A statutory declaration from your employer stating that your employer believes you are competent to fumigate
the selected site environments; and
• Applicants under the Mutual Recognition Act must provide a copy of their inter-state pest management licence
identity card (front and back) if issued.
• If the space provided in any section is insufficient, attach additional documents with the required information,
indicating clearly which section of the form it applies to.
• For information on fees, please see the Pest Management Fees payable section on the Department of Health
website.
• The Department may carry out inquiries in relation to your application as considered necessary.
• Timeframes for processing of applications may take up to 90 days.
How to submit this application
This application must be submitted by post, if you require assistance in relation to completing your application form,
contact the Public Health Licensing Team at [email protected]ld.gov.au.
To submit your application, send the attached application form, accompanied by all supporting documents (verified
where required) and the applicable fee, to:
The Chief Executive
Queensland Health
Public Health Licensing Team
PO Box 2368
FORTITUDE VALLEY QLD 4006
PMTL application - Version 2.0 28/06/22 Page 2 of 5
Queensland Health
APPLICATION FOR A PEST MANAGEMENT LICENCE
Sections 75 and 78 of the Medicines and Poisons Act 2019
Section 70 of the Medicines and Poisons (Pest Management Activities) Regulation 2021
Privacy statement – please read carefully
The personal information and documents collected for the purpose of this application will be securely stored, and only accessible and used by authorised persons for purposes in accordance with the
Medicines and Poisons Act 2019 and Medicines and Poisons (Pest Management) Regulation 2020. Queensland Health may be required to make enquiries of, and exchange personal information with,
other State, Territory or Commonwealth entities regarding any matters relevant to this application. The department will not disclose any personal information provided with this application and supporting
documents to any other third parties without your consent unless required or authorised by law. The Information Privacy Act 2009 (Qld) sets out the obligations for the collection and handling of
personal information by Queensland Health. For information about how Queensland Health protects your personal information, or to learn about your right to access your own personal information,
please see our website at www.health.qld.gov.au.
SECTION 1 – Type of application
New licence (section 75 of the MPA)
(if your licence has expired, you need to apply for a new licence)
Complete all sections except sections 4 and 8
New Licence under Mutual Recognition:
Complete all sections except section 8
Amendment to an existing licence – Licence Number: (section 78 of the MPA)
Complete section 2, all sections that require amending and sections 9 – 11
Replacement of lost/destroyed licence – Licence Number: (section 83 of the Pest Regulation)
Complete section 2, section 8 and sections 9 – 11
SECTION 2 – Applicant details
Surname:
Given name/s:
Date of birth:
Residential address:
P/C:
Postal address:
as per above residential address or
Phone:
Email:
Employment details
Are you:
( Tick 1
box only)
Self-employed (sole trader/individual) in the pest management industry (run your own business)
Employed by a company (incorporated company) in the pest management industry
Not working currently in the pest management industry
Employer/Business details
Business or trading
name:
ABN:
Company name:
ACN:
Business/company
street address:
State:
P/C:
Postal address:
as per above residential address or
Phone:
Email:
SECTION 3 – Type of endorsements required (tick all that apply)
Pest control activity (excluding timber and bird
pests)
Pest control activity in high-risk places
Pest control activity including timber pests
Pest control activity in sensitive places
Pest control activity including bird pests
Fumigation – *complete site details below
PMTL application - Version 2.0 28/06/22 Page 3 of 5
Queensland Health
APPLICATION FOR A PEST MANAGEMENT LICENCE
Sections 75 and 78 of the Medicines and Poisons Act 2019
Section 70 of the Medicines and Poisons (Pest Management Activities) Regulation 2021
Fumigation site environments – only if applying for fumigation activities
Aircraft
Buildings
Burrows
Chambers
Containers
Ship hold
Silo
Soil
Stack
Small ship afloat
(excluding ship
hold)
Other – please specify
SECTION 4 – For Mutual Recognition licence applicants only
Application for Mutual Recognition under:
Section 19 of the Mutual Recognition Act 1992 (Cwlth)
(please this box ONLY if you are currently licensed in the ACT, NSW, VIC, SA, WA, TAS, NT) or
Section 18 of the Trans-Tasman Mutual Recognition Act 1997 (Cwlth)
(please this box ONLY if you are currently licensed in New Zealand)
Current licence jurisdiction:
Licence number:
Licence expiry:
Are there any additional conditions on your current pest management licence?
Yes No
If applying for a fumigation licence under Mutual Recognition, indicate the site environments you are authorised for
under your current fumigation licence. Tick all applicable boxes.
Aircraft
Buildings
Burrows
Chambers
Containers
Ship hold
Silo
Soil
Stack
Small ship afloat
(excluding ship
hold)
Other – please specify
SECTION 5 – Storage premises of pesticides and fumigants (physical address not postal address)
Address where the pesticides/fumigants will be stored:
SECTION 6 – Duration of the licence
Term of licence sought:
1 year
2 years
3 years
4 years
5 years
SECTION 7 – Photographic and signature identification form
The Pest Management Technician ID card will display a photograph of the technician and signature in digital format.
Please attach a colour photograph that meet the specifications listed below.
The photographs must be –
• passport quality
• showing full front view of the applicant’s head and
shoulders
• not smaller than 35mm x 45mm and not larger than
40mm x 50mm
• not more than 6 months old
• good quality colour with no ink or marks on the
image
• sharply focused, not blurred or unclear.
Attach a photograph here
Do not bend or staple
PMTL application - Version 2.0 28/06/22 Page 4 of 5
Queensland Health
APPLICATION FOR A PEST MANAGEMENT LICENCE
Sections 75 and 78 of the Medicines and Poisons Act 2019
Section 70 of the Medicines and Poisons (Pest Management Activities) Regulation 2021
Identity documents
Please submit any of the following documents:
• current Australian passport – or not expired by more than two (2) years; or
• current foreign passport; or
• current Australian driver’s licence – or not expired by more than two (2) years.
SECTION 8 – Requesting a replacement licence
I declare that my existing Pest Management Technicians licence has been lost, stolen or destroyed.
SECTION 9 – Disclosure (attach any relevant documentation)
Have you, the applicant:
a) Been convicted of an indictable offence (drink driving and minor traffic offences are not
indictable offences)?
Yes No
b) Been convicted of an offence against the Medicines and Poisons Act 2019, Pest Management
Act 2001 including the Pest Management Regulation 2003 (repealed) or equivalent legislation
in another Australian jurisdiction?
Yes No
c) Held a licence, approval and/or an endorsement under the Medicines and Poisons Act 2019,
Pest Management Act 2001 including the Pest Management Regulation 2003 (repealed) or
equivalent legislation in another Australian jurisdiction, that was suspended or cancelled?
Yes No
d) Been refused a licence, approval and/or an endorsement under the Medicines and Poisons
Act 2019, Pest Management Act 2001 including the Pest Management Regulation 2003
(repealed) or equivalent legislation in another Australian jurisdiction?
Yes No
SECTION 10 – Consent and declaration
I consent to the Chief Executive making enquiries of, and exchanging information with other Queensland
authorities, any Australian state or territory, or of the Commonwealth, regarding any matters relevant to this
application. If relevant information cannot be obtained from other entities, the Chief Executive will determine
the application on the information available.
I declare that I have the mental capacity to carry out a pest management activity.
I declare that, to the best of my knowledge, all information provided in this application form, or in an
attachment provided, is true and correct.
I understand that if anything has been stated in this application form, or in an attachment provided, that is
false or misleading, any substance authority granted may be suspended or cancelled.
Full name of applicant:
Signature of applicant:
Date (DD/MM/YYYY):
SECTION 11 – Payment of fees
Fee payable
(see schedule 2 of the Pest Regulation)
$
Tick 1 box only
Cheque or Money Order enclosed (payable to Queensland Health)
Payment by Credit Card (complete payments details below)
Note: this is a GST free item. Department of Health ABN 66 329 169 412
PMTL application - Version 2.0 28/06/22 Page 5 of 5
Queensland Health
APPLICATION FOR A PEST MANAGEMENT LICENCE
Sections 75 and 78 of the Medicines and Poisons Act 2019
Section 70 of the Medicines and Poisons (Pest Management Activities) Regulation 2021
Credit card payments – do not overwrite any digits
• This page should only be completed if payment is being made by Mastercard or Visa.
Note: American Express is NOT available
• Please ensure that this page is returned with the application only if paying by this method. Do not return this
page if payment is being made by cheque or money order.
• If an error is made, cross through the digit using a single line and write the correct digit above and initial the
change.
• If emailing application, do not include credit card details with this form. Call to pay over the phone or print this
page and send via post.
Name of Applicant:
Prescribed fee:
$
Tick 1 box only
Mastercard
Visa
Name on card (print)
Expire date:
___ / ___
Signature of cardholder
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Card number: