The Safety Alliance - Apply for Business Certificate Renewal

TSA Apply for Business Certificate Renewal

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* 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:

Details of Previous Queensland Licence:

Licence	Class	Copy Provided
Demolition	DM1	Yes No
	DM2	Yes No
Asbestos Removal	AR1	Yes No

List of Projects Completed in the Last 2 Years:

Client	Project Address	Work	Value of Project	Client Phone	Client Email	Form 34 Attached
		Demo Asbestos				Yes No	Add Another Project

Insurance Type	Policy No.	Expiry	Value	Exclusions	Copy Provided
Work Cover					Yes No
Sickness & Accident (optional)					Yes No
Public Liability					Yes No

List Competent Persons to Supervise(separate approval required):

Name	D.O.B.	Licence Type			Copy of Certificate Provided
Name	D.O.B.	DM1	DM2	AR1	Copy of Certificate Provided
*	*				* 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 Expertise	Company Name	Person	Phone	Email
*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 Licence	Holder	Licence No.	Restrictions (if any)	Expiry	Copy 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?
Note: where you have been required to provide documents, please fax to 07 3102 9111
I declare that the information I have provided is correct: Yes Name: Date:

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