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 4600; Fax 03 6173 0206Email: wstinfo@justice.tas.gov.au Website www.worksafe.tas.gov.au

Department of Justice

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.

You should complete this application for if you wish to:

Suburb

Surname

Residential Address

Given Names

Daytime Contact NumberDate of Birth

Postcode

1. Applicant DetailsTitle

Postal address (if different to above)

Email

Postcode

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

Licence Class(es) Licence Number (if applicable)

Interim Assessment Licence Number (if applicable)

3. Replacement Licence Details (complete if applying to replace a lost/stolen/damaged licence)Provide details of the reason you are applying for a replacement

Current licence Number (if applicable)

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4 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

Signature Date

Application Checklist - What to bring with you to Service Tasmania

I, the applicant, 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

5 Declaration

Your competed application form

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

Your current Licence to perform high risk work 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.

Worksafe Tasmania may refuse to issue, suspend or cancel your licence if you give incomplete, false or wrongful information

Licence to Perform High Risk Work Application

Payment of the appropriate fee

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DO NOT INCLUDETHESE PAGESWITHYOURAPPLICATION

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. You must hold a current Licence to Perform High Risk Work if you operate any of this equipment or perform any of these tasks: HIGH RISK WORK LICENCE CLASSES AND CODES CRANE REACH STACKERS CT Tower crane RS Reach stacker CS Self-erecting tower crane CD Derrick crane RIGGING/DOGGING CP Portal boom crane DG Dogging CB Bridge and gantry crane RB Basic rigging CV Vehicle loading crane Rl Intermediate rigging CN Non-slewing mobile crane (capacity over 3 tonnes) RA Advanced rigging C2 Slewing mobile crane (20 tonnes or less) C6 Slewing mobile crane (60 tonnes or less) SCAFFOLDING C I Slewing mobile crane (I 00 tonnes or less ) SB Basic scaffolding C O Slewing mobile crane (over 100 tonnes ) Sl Intermediate scaffolding HOIST SA Advanced scaffolding HM Materials hoist HP Personnel and Materials Hoist WP Boom-type elevating work platform PRESSURE EQUIPMENT PB Concrete placing boom BS Standard Boiler BA Advanced boiler FORK LIFT TRUCK OPERATOR TO Turbine LF Fork lift truck ES Reciprocating steam engine LO Order picking fork lift truck 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 a 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. How do I lodge my Application Form? Make sure that your application form is completed correctly and you have all supporting documents required. (See Application Checklist on page 2 of the application form) . Take your paperwork in person to a Service Tasmania outlet. The 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

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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

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

Before this licence application can be processed you must establish evidence of identity. To do this 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 and must be original and current:

If there are any queries with your application, WorkSafe Tasmania will contact you on the number you provided.

Please note applications not completed correctly or which do not have the required documentation will not be accepted How do I notify a change of my details? You must notify WorkSafe Tasmania in writing 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).

Fees

New high risk work licence application if you currently don't hold a licence and are applying for I - 3 classes (including transferring an interstate licence) $68.20

New high risk work licence application if you currently don't hold a licence and are applying for more than 3 classes (including transferring an interstate licence) $80.60

Adding a class to a current high risk work licence and applying for I - 3 classes $43.40

Adding a class to a current high risk work licence and applying for more than 3 classes $55.80

Application for a replacement high risk work licence $43.40