Application to renew an interstate Licence to Perform High Risk Work

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FORM 97

Application to renew an interstate Licence to Perform

High Risk Work

V1.7.14

This form is only to be completed for high risk work licences that were issued in a jurisdiction other than Queensland, and are due for renewal within the next three months. Please note: if the licence is an existing Queensland Certificate of Competency or “Old Style” Certificate (issued pre-March 1992), or equivalent interstate issued licence, or an interstate high risk work licence that is not due for renewal or has expired for more than 12 months, please call the department’s Advisory Services on 07 3828 3112.

1. Applicant details

Title ( Dr, Mr, Mrs, Miss, Ms)

First given name Second given name (if applicable)

Family name/surname Date of birth (DD/MM/YYYY)

Identification type (please select one of the following and provide the identification number) Queensland driver’s licence Adult proof of age card I do not hold either of these forms of identification

2. Contact details

You must be a resident of Queensland, or can satisfy Workplace Health and Safety Queensland (WHSQ) that circumstances exist that justify the renewal of the licence in Queensland. For more information, please contact WHSQ prior to submitting your application as the application fee is non-refundable.

Residential address (must be an Australian address and not a PO Box)

Unit no./Street no. Street name

Suburb/ Locality State Postcode Phone number (please provide at least one contact phone number) Telephone Mobile

Email address (if applicable)

Postal address (must be an Australian address)

Cross this box if your postal address is the same as your address above, or provide your postal address details below

PO Box number GPO Box number Private Bag number Locked Bag number Suburb/ Locality State Postcode

3. Interstate licence details

Please provide details of your interstate high risk work licences; if you hold more than three interstate licences please attach these separately. Select only those classes in which you have maintained competency. For a full list of relevant codes for classes of high risk work, please refer to Table 1.0 High risk work classes and codes (page 4).

Interstate licence 1

Licence number State of issue Issue date (dd/mm/yyyy) Expiry date

Endorsements held on this licence

LF LO RS CB CD WP CN CP C2 C6 C1 CT CS BB BI BS

BA C0 CV PB DG HP HM RB RI RA SB SI SA TO ES

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Interstate licence 2

Interstate licence 3

4. Additional information

Having a licence suspended or cancelled, entering into an enforceable undertaking, or having a disqualification or conviction does not automatically exclude you from renewing your licence. Each application will be assessed on the details provided. You may be contacted to supply further information.

Have you ever been convicted or found guilty of any offence under the Work Health and Safety Act 2011 or Work Health and Safety Regulation 2011 or under the work health and safety law of another state, territory or the Commonwealth? This relates to offences under the WHS Act or Regulations or WHS Law only. This does not include offences such as driving infringements, criminal offences or breaches of other legislation.

Yes No (If yes, provide details)

Have you entered into an enforceable undertaking under the WHS Act or the WHS law of another state, territory or the Commonwealth? Yes No (If yes, provide details)

Have you ever had an equivalent high risk work licence under the WHS Act or Regulations or the WHS law of another state, territory or the Commonwealth refused, suspended or cancelled? This relates to high risk work licences only, not any other type of licence.

Yes No (If yes, provide details)

Are you or have you been disqualified from applying for a high risk work licence? Yes No (If yes, provide details)

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5. Declarations by applicant

By signing this application form you are declaring that:

• you do not hold an equivalent high risk work licence granted by a work health and safety regulator in another state, territory or the Commonwealth, unless that licence is due for renewal.

• you 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 application.

• you have maintained competency in all of the high risk work classes listed in this application. • that the information supplied in this application is true and correct to the best of your knowledge.

• none of the information supplied by you in this application or in any documents attached to or submitted in support of this application is false or misleading in any material particular.

• in making this application you have not failed to provide any material information relating to the matters addressed above.

• you acknowledge that it is an offence under the Work Health and Safety Act 2011 to provide false and misleading information in this application or in any documents submitted in support of this application.

Name in full (please print)

Signature Date (dd/mm/yyyy)

PRIVACY STATEMENT: The Department of Justice and Attorney-General is collecting your personal information in order to process your application to renew an interstate licence to perform high risk work 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 work health and safety regulator/s in order to obtain information relevant to making a decision on your application or as otherwise required by law. The government may also disclose your licence status to employers or prospective employers and members of the public who wish to check this status. The status of a licence refers to whether the licence is current or not, the expiry date and any conditions attached to the licence.

6. Checklist of documentation required to present to Courthouse Staff

100 points of identification. For details please refer to table 2.0 Points of Identification (page 4).

7. Checklist of documentation required to submit to Courthouse Staff

Completed application form

Passport quality photograph of yourself. For details please refer to table 3.0 Photograph requirements (page 5)

8. Fee

In order for your application to be accepted, the form must be completed correctly and all supporting documentation must be provided. Please note that your application will not be processed by WHSQ until full payment has been received. The fastest way to make payment is to provide your credit card details below or attach a cheque/money order to your application. If required, BPay details can be provided after your application is received by WHSQ.

Please allow up to 120 days for your application to be processed. If you have any further enquiries regarding your application, please contact Advisory Services on 3828 3112.

The relevant fee is $77.55

Applicants wishing to make payment by credit card or BPay will be contacted by a Processing Officer. Please provide contact details. I have enclosed a cheque or money order (cheques should be made out to Department of Justice and Attorney General), or I wish to pay by credit card, please call me on

I wish to pay by BPay. An application summary including BPay details will be forwarded to you within 5-7 working days. Please cross this box if a receipt is required.

Address receipt is to be sent to (if different to address stated in Section 1)

Street number Street name

Suburb State Postcode Submit your completed application, supporting documents and relevant fee to a Queensland Courthouse, QGAP or QGSC Counter.

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Table 2.0 Points of Identification

Proof of identification

Document type

Document

Point

_value

Primary

You must use ONE primary

document OR at least

ONE secondary document

which MUST contain a

photograph

Full Birth Certificate or Birth Card issued by the Registrar of Births, Deaths and

Marriages

70 Australian Passport (current or expired within the last two years, but not

cancelled)

70 Australian Citizenship Certificate

70 International Passport (current, NOT expired or cancelled)

70 Secondar

Your initial secondary

document will be awarded

40 points, any additional

documents will be awarded

25 points each.

Australian Photo Drivers Licence

40 or 25

Australian Photo Firearm Licence

40 or 25

State or Federal Government Employee Photo Identity

40 or 25

Tertiary Education Institution Photo Identity

40 or 25

Australian Learner’s Permit

40 or 25

Department of Veterans Affairs Card

40 or 25

Centrelink or Social Security Card

40 or 25

Proof of Age Card (issued by Queensland Transport)

40 or 25

Medicare Card

25 Council Rates Notice

25 Property Lease/Rental Agreement

25 Property Insurance Papers

25 Motor Vehicle Registration or Insurance Documents

25 Professional or Trade Association Card

25 Utility Bills (e.g. Telephone, Gas, Electricity, Water)

25 Credit/Account Card

25 Credit/Account Card or Bank Statement/Passbook

25 Only ONE of each document from this category can be used for the proof of identity points.

Code Class

LF Forklift truck – not pedestrian operated LO Order picking forklift truck

CB Bridge/gantry crane CD Derrick crane

WP Boom type elevating work platform CN Non-slewing mobile crane

CP Portal boom crane

C2 Slewing mobile crane 20 tonnes or less C6 Slewing mobile crane 60 tonnes or less C1 Slewing mobile crane 100 tonnes or less C0 Slewing mobile crane over 100 tonnes CV Vehicle loading crane – 10m tonnes or more PB Concrete placing boom

DG Dogging

HP Material or personnel hoist

HM Materials hoist with cantilever platform

Code Class RB Basic rigging RI Intermediate rigging RA Advanced rigging SB Basic scaffolding SI Intermediate scaffolding SA Advanced scaffolding CT Tower crane

CS Self erecting tower crane RS Reach stacker.

BB Basic boiler (Note: holders of this endorsement will be issued with a BS).

BI Basic intermediate (Note: holders of this endorsement will be issued with a BS)

BS Standard boiler operation BA Advanced boiler operation TO Turbine operation

ES Reciprocating steam engine

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Table 3.0 Photograph requirements

You must provide a recent colour passport size photograph of yourself with your application. Your photograph must be no more than six months old and must meet the conditions set out below. If your photo does not meet the required quality requirements, your application will not be accepted. To meet the requirements your photo must:

1. Be within 45-50mm high and 35-45mm wide.

2. Show your head and top of your shoulders close up so the measurement of the face from the bottom of the chin to the crown (i.e. top of head without hair) is between 32 and 36mm.

3. Be printed on high quality paper at high resolution.

4. Show natural skin tones and colours, no flash reflection and no red eye. 5. Show you with natural expression and mouth closed (i.e. not smiling). 6. Have a plain, light-coloured background (e.g. white, cream or pale blue). 7. Show you facing and looking directly at the camera.

8. Show you with no hair across your eyes. 9. Show both edges of your face clearly.

10. Not show you looking over one shoulder (portrait style) or with head tilted. 11. Not be manipulated in any way and must be a single photo of applicant.

12. Show you without hat or head covering unless worn for religion reasons, in which case, facial features from bottom of chin to top of forehead and both edges of your face must be clearly shown.

13. Show your eyes open and clearly visible, and only with glasses if you regularly wear them. You do not have to wear glasses for your passport photo. But if you do, no dark lenses or flash reflections of the lenses, and frames cannot cover any part of your eyes.

Max 36mm

Min 32mm

Passport

quality

photo

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CHECKLIST FORM 97

Application to renew an interstate Licence to Perform

High Risk Work

Courthouse staff use only

Lodged at: Courthouse QGAP QGSC

PLEASE SPECIFY Location:

Applicant details: Name of applicant: Date and time of application:

Signature of Courthouse officer:

Checklist:

Has the applicant completed the Licence to perform High Risk Work interstate renewal application? Has the photo of the applicant been verified?

Has the interstate high risk work licence of the applicant been verified? Please ensure the licence was not issued in Queensland or interstate high risk work is expiring within 3 months and/or has not been expired for more than 12 months.

Expiry date of interstate high risk work licence: ____________________ Classes of high risk work listed on licence: ____________________

Has the applicant displayed appropriate identification documents? Please use the table below to identify which documents were displayed.

Proof of Identification

Document type Document Point _value

Tick if document displayed The applicant must use

ONE primary document OR

At least ONE secondary document which MUST

contain a photograph

Primary

Full Birth Certificate or Birth Card issued by the Registrar of Births, Deaths and Marriages

70

Australian Passport (current or expired within the last two years, but not cancelled) 70

Australian Citizenship Certificate 70

International Passport (current, NOT expired or cancelled) 70

The initial secondary document will be awarded 40 points; any additional documents will be awarded 25 points each.

Secondary

Australian Photo Drivers Licence 40 or 25

Australian Photo Firearm Licence 40 or 25

State or Federal Government Employee Photo Identity 40 or 25

Tertiary Education Institution Photo Identity 40 or 25

Australian Learner’s Permit 40 or 25

Department of Veterans Affairs Card 40 or 25

Centrelink or Social Security Card 40 or 25

Proof of Age Card (issued by Queensland Transport) 40 or 25

Medicare Card 25

Council Rates Notice 25

Property Lease/Rental Agreement 25

Property Insurance Papers 25

Motor Vehicle Registration or Insurance Documents 25

Professional or Trade Association Card 25

Utility Bills (e.g. Telephone, Gas, Electricity, Water) 25

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Only ONE of each document from this category can be used for the proof of identity points.

Credit/Account Card or Bank Statement/Passbook 25

Applicant has provided an ID Waiver Letter from Licensing Services, Workplace, Health & Safety

Has the applicant supplied the method of payment? Please specify:

Cheque or money order included with the correct filing fee or contact details supplied for payment via credit card or Bpay

Workplace Health and Safety Queensland Work Health and Safety Regulation 2011 Applicant to retain the following section as evidence of application

Application to Renew an interstate Licence to Perform High Risk Work

Name of applicant:

Date and time of application:

Signature of Courthouse officer:

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