Department of Justice WorkSafe Tasmania PO Box 56, Rosny Park, TAS 7018 Phone: (in Tasmania)1300 366 322; (outside Tasmania) - 03 6166 4600; Fax 03 6233 8338 Email: [email protected] Website www.worksafe.tas.gov.au Licence to Perform High Risk Work Replacement Application Form Work Health and Safety Regulations 2012 A. Licence Number (if known) B. DETAILS OF APPLICANT Title Surname Given Names Residential Address City/Town Post Code Postal address (if different to above) Post Code Home Phone Mobile Phone Date of Birth Email Sex Reason for Replacement (tick appropriate box) Lost Stolen Damaged Destroyed Not Received Printing Error Describe how the HRW licence was lost, stolen, damaged, or destroyed: I, the undersigned person to whom this application applies, declare that: • • • the information contained in this application is true and correct . I agree to the making of enquiries and the exchange of information between the authorities of any State or Territory regarding my activities relevant to this application and the licence class(es) I hold. I will/ have maintained my competencies in the operation of all classes of equipment endorsed on my Licence to Perform High Risk Work. (To Be Signed in front of a Service Tasmania Officer) Signature of applicant Date Service Tasmania Officer's signature Personal information we collect from you will be used by the Regulator for licensing purposes and may be used for other purposespermitted by the WorkHealth and Safety Act 2012 and associated laws. Failure to provide this information may result in your application being denied or records not being properlymaintained.Your personal information may be disclosed to contractors and agents of WorkSafe Tasmania, law enforcement agencies, courts and other public sector bodies or organisations authorised to collect it. This information will be managed in accordance with the Persona/Information Protection Act 2004 and may be accessed by you on request to this Department.You may be charged a fee for this service. GF086 Page 1 of 2 Expires 30 June 2015 Licence to Perform High Risk Work REPLACEMENT INFORMATION SHEET You should complete the attached application form if you wish to apply for a replacement Licence to Perform High Risk Work: Personal Details If you have not received or have lost your high risk licence, please complete the attached application form. If any of your personal details have changed please make the necessary changes but remember if you have changed your name you will be required to provide documentation as proof. Lodging your Replacement Application Replacement applications must be lodged at a Service Tasmania outlet. When lodging your replacement application you will need to bring: • The completed and unsigned replacement application form • Evidence of identification (see below) • Replacement fee of $41.44 Class descriptions and codes CRANE CT - Tower crane CS - Self-erecting tower crane CD - Derrick crane CP - Portal boom crane CB - Bridge or gantry crane CV - Vehicle loading crane CN - Non-slewing mobile crane (capacity exceeding 3 tonnes) C2 - Slewing mobile crane (20 tonnes or less) C6 - Slewing mobile crane (60 tonnes or less) C1 - Slewing mobile crane (100 tonnes or less ) CO - Slewing mobile crane (exceeding 100 tonnes) HOIST HM - Materials hoist (cantilever platform) HP - Hoist (personnel and materials) WP - Boom-type elevating work platform (boom length 11 metres or more) PB - Concrete placing boom REACH STACKERS RS - Reach Stacker FORK LIFT TRUCK OPERATOR LF - Fork lift truck LO - Order picking fork lift truck RIGGING/DOGGING DG - Dogging RB - Basic rigging RI - Intermediate rigging RA - Advanced rigging SCAFFOLDING SB - Basic scaffolding SI - Intermediate scaffolding SA - Advanced scaffolding PRESSURE EQUIPMENT OPERATOR BS - Standard Boiler BA - Advanced boiler TO - Turbine ES - Reciprocating steam engine Evidence of identity Requirements Please provide at least: • • one document from Category A plus two documents from Category B; or two documents from Category A plus one document from Category B Acceptable forms of identification include the following: Category B Category A (All documents must be original and current) (All documents must be original and current) • • • • • • • • Medicare Card • Plastic Bank or Credit Card, with signature • Tertiary Student card • Department of Veterans' Affairs/Centrelink • Birth Certificate (not an extract) Citizenship papers Australian Passport Overseas Passport/Visa Driver Licence Firearm Licence Department of Immigration and Multicultural Affairs issued travel documents, including a visa Department of Immigration and Multicultural Affairs issued Certificate of Evidence of Residential Status Pensioner Concession Card • Births Deaths and Marriages Change of Name/Marriage Certificate (to prove name change) • Security Guard/Crowd Controller Licence • Government issued Personal Photo ID Card DO NOT INCLUDE THIS PAGE WITH YOUR APPLICATION -INFORMATION ONLY GF086 Page 2 of 2 Expires 30 June 2015