LICENCE TO PERFORM HIGH RISK WORK FORM

SafeWork SA
LICENCE TO PERFORM
HIGH RISK WORK
FORM
CA
CHANGE OF ADDRESS NOTIFICATION
GPO Box 465
Adelaide, SA 5001
Contact: 1300 365 255
www.safework.sa.gov.au
ABN: 50 560 588 327
FOR HELP FILLING IN THIS FORM CONTACT THE SAFEWORK SA HELP CENTRE ON 1300 365 255
Regulation 96 ‘Notice of change of address’ of the Work Health and Safety Regulations 2012 (SA) requires that:
The licence holder of a high risk work licence must give written notice to the regulator of a change of residential address, within 14 days of the change occurring.
Maximum penalty: in the case of an individual – $1250
Expiation fee: in the case of an individual – $144
Use this form if you need to advise SafeWork SA that you have changed your residential or postal address.
STEP 1
– YOUR DETAILS
STEP 3
(Please record your name exactly as it appears on your photo
identification, eg Licence to Perform High Risk Work)
FAMILY NAME (as per your photo identification)
– DECLARATION
I declare that, to the best of my knowledge, the information
provided in and supporting this notification is true and
correct in every particular.
PRINT NAME
GIVEN NAME/S (as per your photo identification)
DATE OF BIRTH
/
APPLICANT’S
SIGNATURE
GENDER
DATE
/
STEP 4 – LODGEMENT INSTRUCTIONS
CONTACT TELEPHONE NUMBER/S
Tel (
)
LICENCE TO PERFORM HIGH RISK WORK NO.
This form must be lodged with SafeWork SA by post,
email or fax together with a copy of your photo ID. You
can do this via:
a) post to: SafeWork SA, High Risk Work Licensing
GPO Box 465, ADELAIDE 5001
COPY OF PHOTO ID ATTACHED (eg Driver’s Licence, Passport)
YES
If Driver’s Licence, please copy front & back of card
A: NEW RESIDENTIAL ADDRESS
END OF NOTIFICATION
AS ABOVE
Postcode
Mobile
Email
STEP 2
b) e-mail to: [email protected]
(providing you have scanned this form and any
attachments); or
If you have any questions about completing this form, please
telephone the SafeWork SA Help Centre on 1300 365 255 or
visit www.safework.sa.gov.au
Postcode
B: NEW POSTAL ADDRESS
– PREVIOUS ADDRESS DETAILS
OFFICE USE ONLY:
Help Centre Officer: .............................................................
Identity Established:
YesNo
Evidence Received:
YesNo
Signature Verified:
YesNo
Details amended on InfoNet:Yes
No
Date: ...........................................
A: PREVIOUS RESIDENTIAL ADDRESS
Licensing Officer: ..................................................................
Amendments Verified:
YesNo
Postcode
0460 - JULY 2015
B: PREVIOUS POSTAL ADDRESS
AS ABOVE
Date: ...........................................
NOTES
Postcode
.......................................................................................
................................................................................................