Department of Justice WorkSafe Tasmania

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:
•
•
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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.
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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)
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•
•
•
•
•
•
• 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
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