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TSA Application for Demolition/Asbestos Business Certificate Queensland Only

* Indicates Required Information

*Organisation Name:
Organisation Structure:
*Organisation ABN:
*Address Line 1 (physical address):  
Address Line 2:  
*Suburb:
*Post Code:


Postal Address (if different):
P.0. Box No.:  
Suburb:
Post Code:


*Contact Name:
Job Title:
*Phone No. (not mobile):
Mobile No.:
*Contact Email:
*Re-enter Contact Email:
Second Email:
*States in which you operate (please select all that apply):
The control key has to be held down while selecting multiple states.
States in which you have offices (please select all that apply):
The control key has to be held down while selecting multiple states.

*Are you Third Party Certified for any of the following:

a) OHS Management Systems to Australian Standard AS 4801
  Certificate No.Expiry
(DD/MM/YYYY)		Copy
Provided
Yes
No




How did you find The Safety Alliance?:
*Type of Business Certificate Applied For: Demolition less than 10m
Demolition - open
Friable Asbestos



*Asbestos Removal applicants only:
The following equipment is mandatory for Friable asbestos removal:
Decontamination unit
Negative air extraction system
Supplied air respirators
Do you own your own equipment? Yes No
If you do NOT own your own equipment please answer the following question:
How do you intend to have this equipment available? Rent
Buy
Borrow
Provide Details of Provider:





Do you hold licences in other states?

yes
no



LicenceClassLicence No.ExpiryRestrictions
(if any)		Copy
Provided
Demolition Yes
No 
Asbestos Removal Yes
No 


Insurance TypePolicy No.ExpiryValueExclusions
Work Cover
Sickness & Accident
(optional)
Public Liability


List Competent Persons to Supervise(separate approval required):
NameD.O.B.Licence TypeCopy of Certificate Provided
DM1DM2AR1
* * *
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No


You do not need to complete the following table if you are only applying for an asbestos licence.
Expertise Available
List Internal or External Persons
Area of ExpertiseCompany NamePersonPhoneEmail
*Engineer - Sructural
Engineer - Mechanical
Engineer - Geotechnical
Engineer - Electrical
Architect
*Plumber
*Gas Fitter
*Electrician
Refrigeration
Fire Systems
*Plant Hire
*Temporary Fence Hire
*Traffic Control
*Scaffold
Gantry
Explosives
Concrete Cutting
*Crane Hire


You do not need to complete the following table if you are only applying for an asbestos licence.
Trade LicenceHolderLicence No.Restrictions
(if any)		ExpiryCopy
Provided
Yes
No 
Yes
No 
Yes
No 
Yes
No 
Yes
No 
Yes
No 
Yes
No 


*Details of Construction Safety Plan:





Compliance With Legislation
*Has the applicant been convicted for a breach of WHS legislation in Queensland or another State/Territory related to the prescribed activity in the previous 10 years? yes
no
*Are there any outstanding improvement, prohibition or infringement notices relating to the prescribed activity, issued under WHS legislation in Queensland or another State/Territory in the previous 2 years? yes
no
*Has the applicant had certificate relating to the prescribed activity in Queensland cancelled or suspended?
OR
Has the applicant had a certificate, licence or approval relating to the prescribed activity in another state or territory cancelled or suspended? 		yes
no
*Has the applicant had an application for a certificate relating to the prescribed activity refused in Queensland of another State/Territory? yes
no


Are you a HEAD CONTRACTOR? Yes No
How many employees do you have?
How many sub-contractors do you have?

I declare that the information I have provided is correct: Yes

Name: Date:




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