Application to renew an interstate Licence to Perform High Risk Work

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1 Workplace Health and Safety Queensland FORM 97 Application to renew an interstate Licence to Perform High Risk Work V 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 Applicant details Title ( Dr, Mr, Mrs, Miss, Ms) First given name Family name/surname Second given name (if applicable) 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 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 Great state. Great opportunity.

2 Interstate licence 2 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 Interstate licence 3 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 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. Have you entered into an enforceable undertaking under the WHS Act or the WHS law of another state, territory or the Commonwealth? 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. Are you or have you been disqualified from applying for a high risk work licence? 2/7

3 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 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 8. Fee Completed application form Passport quality photograph of yourself. For details please refer to table 3.0 Photograph requirements (page 5) 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 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. 3/7

4 Table 1.0 High risk work classes and codes Code Class Code Class LF Forklift truck not pedestrian operated RB Basic rigging LO Order picking forklift truck RI Intermediate rigging CB Bridge/gantry crane RA Advanced rigging CD Derrick crane SB Basic scaffolding WP Boom type elevating work platform SI Intermediate scaffolding CN Non-slewing mobile crane SA Advanced scaffolding CP Portal boom crane CT Tower crane C2 Slewing mobile crane 20 tonnes or less CS Self erecting tower crane C6 Slewing mobile crane 60 tonnes or less RS Reach stacker. C1 C0 CV PB DG HP HM Slewing mobile crane 100 tonnes or less Slewing mobile crane over 100 tonnes Vehicle loading crane 10m tonnes or more Concrete placing boom Dogging Material or personnel hoist Materials hoist with cantilever platform BB BI BS BA TO ES Basic boiler (Note: holders of this endorsement will be issued with a BS). Basic intermediate (Note: holders of this endorsement will be issued with a BS) Standard boiler operation Advanced boiler operation Turbine operation Reciprocating steam engine Table 2.0 Points of Identification Proof of identification Document type Primary You must use ONE primary document OR at least ONE secondary document which MUST contain a photograph Secondar Your initial secondary document will be awarded 40 points, any additional documents will be awarded 25 points each. Document Full Birth Certificate or Birth Card issued by the Registrar of Births, Deaths and 70 Marriages Australian Passport (current or expired within the last two years, but not 70 cancelled) Australian Citizenship Certificate 70 International Passport (current, NOT expired or cancelled) 70 Point value 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. 4/7

5 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. Passport quality photo 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. Min 32mm Max 36mm 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. AEU 14/5166 5/7

6 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 The applicant must use ONE primary document OR At least ONE secondary document which MUST contain a photograph The initial secondary document will be awarded 40 points; any additional documents will be awarded 25 points each. Document Primary Full Birth Certificate or Birth Card issued by the Registrar of Births, Deaths and Marriages 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 Secondary Point value 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 Tick if document displayed 6/7

7 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 AEU 14/5166 Applicant to retain the following section as evidence of application Workplace Health and Safety Queensland Work Health and Safety Regulation 2011 Application to Renew an interstate Licence to Perform High Risk Work Name of applicant: Date and time of application: Signature of Courthouse officer: 7/7

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