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TO BE ACCOMPLISHED IN DUPLICATE This form is NOT FOR SALEand may
be REPRODUCED
DEPARTMENT OF LABOR AND EMPLOYMENTOccupational Safety and Healt
Cente! OSH"C"N
APPLICATION FORM FOR OSH CONSULTANT(NEW) Page 4 of 4
CHARACTER REFERENCES ive at #ea"t )%
Name Address Contat No# E-mail Address
Do yo! ha/e any 2endin3 administrati/e aseG +es.No, If ES<
2lease 3i/e details#
Do yo! ha/e any 2endin3 riminal aseG +es.No, If ES< 2lease
3i/e details#
Ha/e yo! e/er on/ited of any administrati/e oenseG+es.No, If
ES< 2lease 3i/e details#
Ha/e yo! been on/ited of any rime or /iolation of any la;<
deree< ordinane orre3!lations by any o!rt or trib!nalG +es.No,
If ES< 2lease 3i/e details#
Ha/e yo! e/er been retired< fored to resi3n or dro22ed from
em2loyment in the 2!bliand.or 2ri/ate setorG +es.No, If ES<
2lease 3i/e reasons#
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8/10/2019 OSH Consultant Accreditation Form
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* certify t$at t$e information "tated above i" true and
correct#
S#1NATURE DATE
TO BE ACCOMPLISHED IN DUPLICATE This form is NOT FOR SALEand may
be REPRODUCED
DEPARTMENT OF LABOR AND EMPLOYMENTOccupational Safety and Healt
Cente! OSH"C"R
APPLICATION FORM FOR OSH CONSULTANT(RENEWAL) Page 1 of
4#NSTRUCT#ONS$
Please attahyo!r
%& ' %& Pictu!e
( COP#ESSi)ned at te
*ac+
Areditation NO# Date of $irst
AreditationDate of Lastrene;alalidity
"# $ill in all the data needed#%# Use BLOC,-PR#NTEDletters or
!se a
TYPE.R#TER# 'rite N-Aif the blan(s are NotApplica*le#
)# Please /i)n in all pa)e/of the form#
PERSONAL PROFILE
TITLE $I*ST NAME MIDDLENAMELASTNAME
City Address +Number & Street, Town/City, Province,Zip
Code,
Home Tel#No#
Mobile No#
E-mail
P*C LienseNo#
Home. Pro/inial AddressDate ofBirth
Se0
Citi1enshi2Ci/ilStat!s
COMPANY PROFILE
B!siness Address E-mail Address Co# Tel# No# *e3ion
'ebsite $a0 No# 4i2 Code
Nat!re of B!siness Em2loyment Si1e
Male $emale Total
Ty2e of Ser/ie
'or(2lae
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8/10/2019 OSH Consultant Accreditation Form
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S2ei5 Prod!t Ha1ardo!s Non-Ha1ardo!s
.OR, E'PER#ENCE+Use additional sheet if neessary,# Please
attahori3inal erti5ate of em2loyment and 6ob desri2tion d!ly
erti5ed by thePersonnel Mana3er.em2loyer. or a!thori1ed om2any
o7ial !sin3 o7ialom2any letter head8 and 2roof of 2ratie +safety
re2ort.2ro3rams2re2ared.im2lemented,
Total ears ofOSH E02eriene
Position +$rom *eent toPresent
Inl!si/eDates
Len3thof
Ser/ie
Stat!s ofA22ointme
ntCom2any
$rom To
TO BE ACCOMPLISHED IN DUPLICATE This form is NOT FOR SALEand may
be REPRODUCED
DEPARTMENT OF LABOR AND EMPLOYMENTOccupational Safety and Healt
Cente! OSH"C"R
APPLICATION FORM FOR OSH CONSULTANT(RENEWAL) Page 2 of 4
DOCUMENTARY REQUIREMENTS
*EMA*:ST;o +%, o2ies of d!ly aom2lished A22liation $orm
+OSH-C-*,;ith % o2ies most reent " 0 " ID 2it!re si3ned at the
ba(+bl!e ba(3ro!nd,#S!mmary of A22liantJs Aom2lishments as OSH
Cons!ltantsi3ned by the em2loyer ors!2er/isor !sin3 o7ial
letterhead ofthe om2any#Proof.s of aom2lishment or 2artii2ation in
OSH
Aident re2orts Safety ins2etion.a!ditre2orts HSC ommittee re2ort
OSH 2ro3ram 2re2ared.
im2lemented Other re2orts 2re2ared by the a22liant 2lease
s2eifyPhotoo2y of Certi5ate of Areditation +last iss!ed,Photoo2y of
other OSH related trainin3s.seminar attended as2artii2ant after
last rene;al of areditation- at least "@ ho!rs2er year or )>
ho!rs of trainin3s for & years< earned from
DOLEreo3ni1ed.aredited STO.instit!tions a!thori1ed by la;#'hen
There is a Chan3e of Em2loyer.Position
Ori3inal Certi5ate of Em2loyment indiatin3 name< 2ositionand
date of a22ointment at 2resent 2osition< !sin3 o7ialletterhead
of the om2any#
Ori3inal Certi5ate of at!al D!ties and *es2onsibilities
at2resent 2osition< !sin3 o7ial letterhead of the om2any
