FORM 79 V7.3.12 ABN 13 846 673 994 Nomination of additional supervisor for demolition work licence Work Health and Safety Act 2011 Please refer to the information papers D1 ‘Approved criteria for a certificate to carry out demolition work’ and D2 ‘Requirements to supervise demolition work’ available at www.worksafe.qld.gov.au or by phoning WHSQ on 1300 655 986. Note: Unsigned or incomplete nominations or nominations not accompanied by the required documentation cannot be processed and may be returned. A separate form must be completed for each additional supervisor 1. Licensee details Name of licence holder (as it appears on the licence): Licence number: Suburb/locality: Postcode: State: Contact person Title (Mr, Mrs, Miss, Ms): Family name/surname: First given name: Second given name (if applicable): Telephone: Mobile: Facsimile: Email: 2. Details of supervisor Title (Mr, Mrs, Miss, Ms): Family name/surname: First given name: Second given name (if applicable): Date of birth (DD/MM/YYYY): Residential address (must be an Australian street address and not a PO box): Unit number/ street number/ street name Suburb/locality: State: Postcode: Telephone: Mobile: Facsimile: Email address (if applicable): Postal address (must be an Australian address) PO box number: Suburb: (details continue over page) GPO box number: Private bag number: Locked bag number: State: Postcode: page 1 of 2 JAG 12/4304 Tick this box if the postal address is the same as the address above 3. Declaration by applicant I declare that: • I have authority from the corporate body to complete and submit this nomination (corporate body applicants only). • The information supplied in this nomination form is true and correct to the best of my knowledge. • N one of the information supplied by me in this of nomination form or in any documents attached to or submitted in support of this nomination is false or misleading in any material particular. • In making this nomination I have not failed to provide any material information relating to the matters addressed above. • I acknowledge that it is an offence under the Work Health and Safety Act 2011 to provide false and misleading information in this nomination or in any documents submitted in support of this nomination. • This nominated supervisor is at least 18 years old. I consent to Workplace Health and Safety Queensland making enquiries and exchanging information with work health and safety regulators in other states, territories or the Commonwealth regarding any matter relevant to this nomination. Dated: Name in full (please print): Signature: PRIVACY STATEMENT The Department of Justice and Attorney-General is collecting your personal information in order to process your nomination of additional supervisor in accordance with the Work Health and Safety Act 2011. It is the department’s usual practice to disclose this information to the applicable Commonwealth, state or territory health and safety regulator/s in order to obtain information relevant to making a decision on your nomination. The department may also disclose your licence status to employers or prospective employers and members of the public who wish to check this status. 4. Checklist of additional documents required Return original licence document (for endorsement of proposed amendment) For each nominated supervisor Evidence of identification A statutory declaration attesting to a working knowledge of the workplace health and safety management system held by the applicant Evidence of three years of relevant demolition industry experience and experience in supervising a minimum of three major building / structural demolition projects Evidence of the successful completion of 30765QLD course or equivalent Where to send the completed and signed form: [email protected] Fax: (07) 3247 9453 page 2 of 2 JAG 12/4304 Post: Licensing Services Workplace Health and Safety Queensland PO Box 820 Lutwyche QLD 4030