renewal form - Nova Scotia Apprenticeship Agency

Nova Scotia Apprenticeship Agency
PO Box 578, 2021 Brunswick St.
Halifax, NS B3J 2S9
Telephone: (902) 424-5651
Toll Free: 1-800-494-5651
Fax: (902) 424-0717
RENEWAL APPLICATION - CERTIFICATE OF QUALIFICATION
PLEASE PRINT
Trade
Classification (Blasters only)
Trade Code
Registration #
Application #
The Agency will use and disclose personal information only in accordance with the Nova Scotia Freedom of
Information and Protection of Privacy Act and the Nova Scotia Personal Information International Disclosure
Protection Act. To correct or access your personal information you may contact the Department Information
Access and Privacy Manager at [email protected] or (902) 424-8472.
Full Name
First Name
Middle Name
Last Name
Address
City/Town
County
Postal Code
Home Phone
Province
Business
Phone
Social Insurance Number
Date of Birth
Certificate of Apprenticeship #
Date Issued
Certificate of Qualification #
Date Issued
Interprovincial Red Seal #
Date Issued
Not Trade Employed (date)
Retired G Yes (date)
Blaster Trade Only: To renew a Blaster certificate, you must attend training prior to renewal. Did you
attend the required training? Yes G No G If Yes, provide date:
RELEASE OF ELECTRONIC PHOTOGRAPH AND SIGNATURE
I hereby authorize the Department of Service Nova Scotia and Municipal Relations to provide my driver’s license or
identification card photograph and signature electronically to the Nova Scotia Apprenticeship Agency for use on my
identification card.
Client Name
Client Master Number
(please print)
(Driver's License)
Signature
Date
Method of Payment: G Certified/Business Cheque
G Money Order
G Visa
G Master Card
G Debit Card
(in person only for debit)
(credit card account number)
IS THIS YOUR CREDIT CARD? Y N
(card holder’s name)
(expiry date)
(signature)
IF NO, ADDRESS FOR RECEIPT PURPOSES:
•
Please enclose your fee payable to the MINISTER OF FINANCE in the amount of $74.18 and forward completed
application to the address above. Cash and personal cheques are not accepted.
•
Payments, including Debit and Credit, are accepted at all branch locations.
RACQ V1.05, 2015-April-01
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