Licence to Perform High Risk Work Application

WorkSafe Tasmania PO Box 56, Rosny Park, TAS 7018 Phone: (in Tasmania)1300 366 322; (outside Tasmania) - 03 6166 4600Email: wst.licensing@justice.tas.gov.au Website www.worksafe.tas.gov.au

Department of Justice

Expires 30 June 2020GF083

Identification sightedDocumentation attachedFee collected

Service Tasmania Office Use Only Product Code LHRW

Declaration signedPhotograph taken

Licence Application Type (tick one)

Apply for a Licence to Perform High Risk work; or Apply for a replacement licence; or

Add an additional class(es) to an existing licence; or Transfer an existing interstate licence to a Tasmanian licence.

Current High Risk Licence Number (if applicable)

Reciprocating Steam Engine Operation (ES)

Turbine Operation (TO)

Advanced Boiler Operation (BA)

Standard Boiler Operation (BS)

Pressure Equipment Operation Advanced Rigging (RA)

Intermediate Rigging (RI)

Basic Rigging (RB)

Dogging (DG)

Dogging and Rigging Work Advanced Scaffolding (SA)

Intermediate Scaffolding (SI)

Basic Scaffolding (SB)

Scaffolding Work Order Picking Forklift Truck (LO) Forklift Truck (LF)

Forklift Operation

Reach Stacker (RS)

Concrete Placing Boom (PB)

Personnel and Materials Hoist (HP)

Materials Hoist (HM)

Portal Boom Crane (CP)

Derrick Crane (CD)

Self Erecting Tower Crane (CS)

Tower Crane (CT)

Slewing Mobile Crane with a capacity over 100 tonnes (C0)

Slewing Mobile Crane with a capacity up to 100 tonnes (C1)

Slewing Mobile Crane with a capacity up to 60 tonnes (C6)

Slewing Mobile Crane with a capacity up to 20 tonnes (C2)

Boom Type Elevating Work Platform (WP)

Bridge and Gantry Crane (CB)

Non-Slewing Mobile Crane (CN) Vehicle Loading Crane (CV)

Crane and Hoist Operation

2. I am applying for the following licence class(es)

1. Applicant Details

Suburb

Surname

Residential Address

Given Names

Daytime Contact NumberDate of Birth

Postcode

Title

Postal address (if different to above)

Email

Postcode

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5. Licence Cancellation/suspension /refusal details

Do you hold an equivalent licence issued in another State or Territory? Yes No

Have you ever been convicted or found guilty of any offence under the Work Health and Safety Act or Regulations 2012 or under any equivalent work health and safety law of another State or Territory?

Yes No

Have you entered into any enforceable undertakings under the Work Health and Safety Act or Regulation 2012 or under any equivalent work health and safety law of another State or Territory?

Yes No

Has any licence you held issued under an equivalent work health and safety law been suspended, disqualified, cancelled or had condition(s) imposed?

Yes No

Have you had any application for a licence issued under an equivalent work health and safety law refused? Yes No

If you answered YES to any of the above questions provide full details below

Application Checklist - What to bring with you to Service Tasmania

declare that the information contained in this application is true and correct and I agree to the making of enquiries and the exchange of information between the authorities of any State or Territory regarding this application and the licence class(es) I hold

6. Declaration

Your completed application form

Your interim licence and assessment summary for new or additional class(es) - white copy

Your current high risk work licence if transferring from another State or Territory or adding an additional class to an existing licence

Evidence of identity documents

Personal Information Protection Act 2004 Personal information we collect from you will be used by the Regulator for licensing purposes and may be used for other purposes permitted by the Work Health and Safety Act 2012 and associated laws. Failure to provide this information may result in your application being denied or records not being properly maintained. 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 Personal Information Protection Act 2004 and may be accessed by you on request to this Department. You may be charged a fee for this service.

Licence to Perform High Risk Work Application

Payment of the appropriate fee (see www.worksafe.tas.gov.au for current fees)

Provide details of the reason you are applying for a replacement licence

4. Replacement Licence Details (complete if applying to replace a lost/stolen/damaged licence)

Lost Stolen Damaged Error

Signature Date

I, (full name)

Interim Licence Number: Interim Licence Number:

If applying for a new licence or adding an additional class insert number of your Assessment Summary and Interim Licence form. This number can be found in red in the top right hand corner of the form.

3. Assessment Summary and Interim Licence Number(s)

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DO NOT INCLUDE THIS PAGE WITH YOUR APPLICATION

What is a Licence to Perform High Risk Work? This is a licence issued either by Worksafe Tasmania under the Work Health and Safety Regulations 2012, or another State or Territory under their work health and safety laws. How do I apply for a Licence to Perform High Risk Work? Before applying for a new licence or adding an additional class to a current Licence to Perform High Risk Work, you must have successfully completed training and competency assessment with a Tasmanian accredited Assessor in the class of high risk work you wish to apply for. The Assessor will give you an Assessment Summary and Interim Licence. You must then apply for your licence at a Service Tasmania outlet within 60 days from the date of issue. Make sure that your application form is completed correctly and you have all supporting documents required. Take your paperwork in person to a Service Tasmania outlet and a Service Tasmania Officer will: • check your application form and supporting documentation, • verify that you are the person in the application by acknowledging your evidence of identity, • take your photograph, • accept your application fee and provide you with a receipt, and • forward your application to WorkSafe Tasmania. Your licence will be mailed to your nominated postal address. Please allow 4-5 weeks for delivery and call our Helpline on 1300 366 322 for advice if your licence is not received within 60 days. Failure to do so may incur a replacement licence fee.

INFORMATION ONLY

Evidence of Identity (documents must be original and current) • one document from Category A plus two documents from Category B; or • two documents from Category A plus one document from Category B

Category A

• Birth Certificate (not an extract) • Citizenship papers • Passport • 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

Category B

• Medicare Card • Bank or Credit Card, with signature • Tertiary Student card • Department of Veterans' Affairs/Centrelink

Pensioner Concession Card • Births Deaths and Marriages Change of Name/

Marriage Certificate • Security Guard/Crowd Controller Licence • Government issued Personal Photo ID Card

How do I notify a change of my details? You must notify WorkSafe Tasmania within 14 days if: • Your residential/postal address details change; or • You change your name (you must provide proof of your change of name to WorkSafe Tasmania); or • You become unable to competently perform the high risk work due to physical or mental incapacity or any other medical reason; or • Your licence is cancelled or suspended by another Authority. How do I renew my Licence to Perform High Risk Work? You must renew your Licence to Perform High Risk Work every five years. WorkSafe Tasmania will send a renewal notice to your last known postal address or you can complete a renewal application form (GF084) and lodge it at a Service Tasmania outlet. How do I replace a Lost, Damaged or Destroyed Licence? If your WorkSafe Tasmania issued Licence to Perform High Risk Work is lost, damaged or destroyed you can apply for a replacement. You will be required to pay a fee, complete this application form stating the reason for applying for a replacement (please contact WorkSafe Tasmania first to confirm your licence number).