A4APPLCIANT DECLARATION#

I …………………………….……., as a representative of ………………………..………….………., (name of applicant) (name of company) acknowledge and verify that all information provided above is true and agree to the following:

• that I will inform the Department of Transport and Main Roads (department) should any of the information provided above change
• if the information provided above is found to be incorrect, whether knowingly or unknowingly, the department may at its own volition remove the product from the accepted products register, and
• the department may at any time request additional information regarding any aspect of the product, sourcing and manufacturing process.

SIGN …………………………………………. …….…/……/………… (Signature) (Date)

For departmental completion only:

Reviewer Name: ………………………………….. Date: …………………………………

• Yes, product is accepted for use in Queensland
• No, product is not accepted for use in Queensland.

Accepted for use: SIGN Reviewer Signature: …………………………………..

• New Application (Date:………………..)
• Renewal (Date: ……………….)

Application Status: