UK-PHMES CSCS Registration Card Application Form

Transcription

1 UK-PHMES CSCS Registration Card Application Form Return Address: JIB-PMES, Lovell House, Sandpiper Court, Phoenix Business Park, Eaton Socon, St. Neots, Cambridgeshire, PE19 8EP. Section 1 Your Details Title (Mr, Mrs, etc): First name: Surname: Home address: Postcode: NI Number: Date of Birth D D M M Y Y Y Y Home Telephone Number: Mobile Telephone Number: Address: Please provide your union membership number. If you are a member of Unite the Union, you may be entitled to a free card. CARD DETAILS New (see below) Renewal of existing card (complete section 19) Type Cost Sections required Plumber Blue 30 1,2,3 & 4 Plumber Gold 30 1,2,3 & 5 Heating Fitter Blue 30 1,2,3 & 6 Heating Fitter Gold 30 1,2,3 & 7 Mechanical Pipe Fitter Blue 30 1,2,3 & 8 Mechanical Pipe Fitter Gold 30 1,2,3 & 9 Gas Service Fitter Blue 30 1,2,3 & 10 Gas Service Engineer Gold 30 1,2,3 & 11 Plumbing Related Occupations (Gas) White 30 1,2,3 & 12 Plumbing Related Occupations White 30 1,2,3 & 13 General Operative/Labourer Green 30 1,2,3 & 14 Plumbing Apprentice/Trainee Red 20 1,2,3 & 15 Supervisor Gold 30 1,2,3 & 16 Manager Black 30 1,2,3 & 17 Site Visitor Yellow 30 1,2,3 & 18 Affix photo here Remember to write your NI number on the back Please make cheques payable to JIB-PMES. FAST TRACK OPTION For an additional payment of (plus standard card fee) you can request that your card is fast tracked. We aim for you to receive your card within 4 working days. In order to process a fast track application we require a completed application form, all supporting documentation and cleared payment by credit/debit card, postal order or BACS transfer (cheques not acceptable). Please tick this box to fast track your application:

2 Section 2 Health, Safety and Environment Training SECTION 2: Health, Safety and Environment Training 1. NVQ/SVQ Exemption If you have obtained relevant Level 2 or 3 National or Scottish Vocational Qualification (NVQ/SVQ) or NVQ Diploma within the past two years, tick this box: (To ensure the NVQ/SVQ exemption is accepted, you must attach a copy of your NVQ/SVQ or NVQ Diploma completion certificate to this application). Please Note: C&G 6129 or 6035 VRQ certificates are NOT acceptable. The exemption period is for a maximum of 2 years from the date on the completion certificate. 2. CITB Health, Safety and Environment (HS&E) Test If you have completed the CITB HS&E test (Plumbing or Gas) please tick this box this application. and ensure you send a copy of your test pass letter with 3. CITB Supervisors + CITB Managers and Professionals HS&E Test If you have completed either the CITB Supervisors or the CITB Managers and Professionals HS&E Test please tick this box send a copy of your test pass letter with this application. and ensure you 4. Other applicable Health and Safety Tests If you have completed any other applicable Health and Safety tests/courses please tick this box and ensure you send copies of your test/ course certificates or test pass letter with this application. Failure to provide a copy of your H&S test pass could result in your application form being returned. For a list of acceptable tests, please visit our website: Section 3 Declaration SECTION 3: Applicants Declaration I certify that the details on this application form are correct and completed to the best of my knowledge. I agree that the information contained on this application form may be used by the JIB-PMES and its related companies in connection with my application for a UK JIB-PHMES card and the provision of other services associated with my employment in the plumbing and mechanical engineering services industry. I acknowledge that the personal information given here will be used for the purpose of processing my application for a UK JIB-PHMES card, and that this may include passing on information to Employers, Labour Agencies or Training Providers and for purposes of verification. I also agree that information from this application may be held on a database in accordance with the Data Protection Act Important Information: * If your application has been through the initial assessment stage and you decide to withdraw your application an administration fee will be deducted from the refund of your fee. * The card remains the property of the JIB-PMES and can be withdrawn at any time. * If all the relevant documentation is not enclosed with the application form, all documentation will be returned. * I agree and accept that the JIB-PMES bear no responsibility or liability for my Registration Card should it be lost in the post. Signed: Date: D D M M Y Y Y Y Notes: The website contains all the latest amendments to the UK-PHMES Registration Scheme rules or call

3 Section 3A Credit/Debit card payment authorisation I hereby authorise the JIB-PMES to charge the required fee (plus any applicable handling charges) to my credit/debit card as detailed below. Cardholder signature: Date: Upon receipt of this instruction the JIB-PMES will process the amount to be paid in accordance with the appropriate fee plus handling charge. Card details Cardholder name: Cardholder daytime contact number (including STD code): Cardholder address (billing address for card statements): Card number: Expiry date: M M / Y Y Postcode: Security code: Last 3 digits on signature strip on back of card Note: If the JIB-PMES is unable to process payment from the Credit/Debit card that is specified, the application will be rejected.

4 Section 13 Plumbing Related Occupations White Card (For guidance notes see reverse) Name National Insurance Number Plumbing Related Occupations White Card Please tick the box which best describes your occupation - this will be put on the back of your card (Tick one box only) Pump Installer Flue Fitter/Installer Solar Heating Installer CCTV Drainage Supplier Swimming Pool Installer RPZ Valve Engineer Fuel Tank, Pipework and Fuel Pump Installer Laundry Equipment Installer Unvented System Installer Medical Gas Services Installer/Engineer Chlorination and Disinfection Lead Worker (and other sheet Equipment Installer weathering) Installer The above list is not exhaustive. If your occupation is not covered please describe the job role you perform. An appropriate occupation title will be chosen for you. CURRENT EMPLOYMENT STATUS Please tick one of the following: Self employed (If self employed, applicants must provide details of a company or JIB-PMES registered agency they have worked for, not their own company details) Employed JIB-PMES Participant Company Y/N EMPLOYER S DECLARATION I certify that the details provided by the applicant are correct to the best of my knowledge. The applicant has been known to me for Name of Employer/Company years. Address Postcode Address Telephone Number Signed Date D D M M Y Y Y Y Print Name Position in Company

5 Section 13 Guidance Notes: Plumbing Related Occupations (White Card) i ii. iii. iv. A White UK-PHMES CSCS Registration Card is issued to those working in Plumbing Related Occupations (e.g. swimming pool installation, sheet weathering, medical gas specialists) who pass the CITB Health, Safety and Environment test. UK-PHMES CSCS Registration Cards are valid for up to five years, and may be renewed after that period (subject to renewal rules). This route of entry is permanently open. To obtain a White Plumbing Related Occupations UK-PHMES CSCS Registration Card, applicants must: Correctly complete the application form and supply the appropriate fee. Provide evidence of completing appropriate Health, Safety and Environment training (CITB or other applicable test/course). Provide a detailed description of the type of work the applicant undertakes together with confirmation from an employer validating experience in this field.