Fillable APPLICATION FORM - INDIVIDUAL (Innovation and Science Australia)

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APPLICATION FORM - INDIVIDUAL (Innovation and Science Australia)

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APPLICATION FORM - INDIVIDUAL
Contractor Licence (Q), Qualified Supervisor Certificate or
Tradesperson Certificate
Are you applying based on an Offshore Technical Skills Record?
Yes
Individual Contractor Licence (Q)
No
Qualified Supervisor Certificate
Tradesperson Certificate (Plumbing, Draining and Gasfitting and a Provisional Certificate for applicants with an Offshore Technical Skills Record)
What type of licence or certificate are you applying for?
1. Type of Application
2. Duration of Licence
Office Use Only: Do not stamp this form Location of SNSW/GAC:
Application No: Licence No:
NSW FAIR TRADING
FN10A
A licence period of 1 year, 3 years or 5 years is available for all home building licenses. Please select
Do you require:-
Variation to an existing current Licence/Certificate No.
OR
Application to reapply for a previously held Licence/Certificate No.
1 year 3 years 5 years
Do you hold or have you previously held a licence, certificate, registration for residential building or specialist work?
Note: You will be reissued the same Licence/Certificate No. as your most recently expired Licence/Certificate No being reapplied for.
No
Yes
Licence/Certificate number
Date of expiry
Issuing authority & state
Work category
Family name (surname)
Given names
Date of birth
Male
Female
Postal address Note: Correspondence will only be sent to this address if an email address has not been provided.
Postcode
Postcode
Residential/Business address (not PO Box)
Home phone number
Business phone number
Email address Note: Correspondence will be sent via email where this has been provided.
Mobile phone number
3. Details of Applicant
13 32 20
www.fairtrading.nsw.gov.au
HB001
07-2020
PAGE 1
Roof plumbing
Roof slating
Roof tiling
Stonemasonry
Swimming pool repairs & servicing (non-structural)
Glazing
Joinery
Metal fabrication
Painting
Plastering (dry)
Plastering (solid/wet)
Wall & floor tiling
Waterproofing
Underpinning/Piering
4. Category of Work
Erection of pre-fabricated metal-framed home additions and structures
Structural landscaping
General building work
Swimming pool building
(includes all types of pools & spas)
Kitchen, bathroom and laundry renovation
Place an ‘X’ next to the category(ies) for which this application or variation is being made.
BUILDING WORK
Bricklaying
Carpentry
Decorating
Excavating
Fencing
General concreting
TRADE WORK
Bitumen surfacing
Ducting & mechanical ventilation
Kitchen/Bathroom bench installation
Paving
Shade sails / systems
Shower screen enclosures
Splash-backs
Minor Tradework
Minor Maintenance Cleaning
SPECIALIST WORK
Pressure washing/graffitti removal/brick cleaning
Repairs non-structural
Resurfacing, bathroom tiles, baths
Electrical wiring
Air-conditioning
Disconnection & reconnection of fixed electrical equipment
Hot water heaters (only eligible for Qualified Supervisor Certificates or as a variation to an existing Plumbing Contractor licence)
Appliances (only eligible for Qualified Supervisor Certificates or
as a variation to an existing Plumbing Contractor licence)
Motors (only eligible for Qualified Supervisor Certificates or
as a variation to an existing Plumbing Contractor licence)
Note: the class of roof plumbing is under TRADE WORK
Note: If applying for the full category of Plumbing – you are not required to also complete this section
Plumbing (Plumbing includes water and sanitary plumbing)
Draining
LP Gasfitting
Water Plumbing (includes Urban Irrigation, Fire Protection Systems and Fire Sprinkler Systems)
OR
Urban irrigation
Gasfitting
Advanced LP Gasfitting
Refrigeration
5. Questions relating to qualifications and experience.
Was your qualification(s) issued solely by a process of recognition of prior learning assessment?
Yes
Yes
No
No
Note: This does not include any qualifications delivered through classroom based training.
Are you a current apprentice or trainee?
Note: A licence or certificate cannot be issued to an applicant who is still in a current a contract of training either as
an apprentice or trainee. For information on early completion go the State Training Services website.
If you have completed an apprenticeship or traineeship: Completion date:
Trade area:
PAGE 2
HB001
07-2020
Fire Protection Systems (includes Fire Sprinkler Systems)
Fire Sprinkler Systems
6. Employment and Experience History
For General Building and Specialist Work ONLY.
You are not required to complete this section of the form if you are applying for Trade Work or Other building work.
Detail your practical experience. All General Building and Specialist Work applicants MUST include a complete employment history for the past 10 years
and up to current date, including where an individual has been previously licensed, self-employed or unemployed.
i. Please place an X in any of the following if you have ever:
Had other names or aliases that you have also been known as
If you have placed an X in the above, complete the “ ” .Additional Details Form 1
ii. Please place an X if you have ever had any of the following compliance matters arising from your activities related to carrying out of
residential building or specialist work by you as an individual or as a director of a company or as a member of a partnership:
Any complaints lodged
Any disciplinary action or proceedings including penalty notices, infringement notices, warnings or formal cautions.
Any disqualifications from holding a licence or applying for a new licence
Any previous licence/certificate suspension or cancellation
Any refusals of licence/certificate application
Any orders of a Tribunal or other Court Orders
Any paid or pending insurance claims against contracts entered into
If you have placed an X in any of the above, complete the “ ” . Additional Details Form 2
iii. Place an X if you have had:
Any criminal history within the last 10 years
This includes:
• Any recorded conviction for a criminal offence
• Being subject to a bond
• Any pending criminal charges
• Incarceration
• Being on parole or subject to any parole conditions
If you have placed an X in the above, complete the “ ” . Additional Details Form 3
iv. Please place an X if within the last 3 years you have been:
Declared bankrupt
Discharged from bankruptcy
Entered into arrangements with creditors or assigned your property to pay debts
If you have placed an X in any of the above, complete the “ ” . Additional Details Form 4
v. Please place an X if you:
Are or have been a director of a company that has experienced any insolvency issues
Ceased being a director of a company and within 12 months of the resignation, the company experienced any insolvency issues
Insolvency issues include:
• Being subject to a winding up order (including creditors' voluntary winding up and/or court ordered winding up)
• Having a controller appointed, or entered into other arrangements with creditors due to insolvency
• Placed in receivership or administration, or under official management
If you have placed an X in any of the above, complete the “ ” . Additional Details Form 5
vi. Please place an X if you are currently:
An involuntary, forensic or correctional patient within the meaning of the Mental Health Act 2007 (NSW)
A protected person within the meaning of the NSW Trustee and Guardian Act 2009 (NSW)
You should check online or call us on 13 32 30 to see if you need to provide fully completed Referee statements' from licensed supervisors for the
category you're applying for. If yes, they MUST also accompany this application.
Period of Employment
(DD/MM/YYYY)
Name and address of employer or contractor who engaged you
Type of work
PAGE 3
7. Declaration Questions
• You MUST read each of the questions below and mark an X against matters that you need to declare
• For any declared matters, you MUST provide full details on the relevant additional details forms(s) if applicable. If the required additional details
form(s) are not provided, your application will be considered incomplete and may be refused.
Have you read i. to vi. above and had nothing to declare? Then tick here to confirm that you do not need to provide any additional details
for assessment.
HB001
07-2020
It is recognised that new applicants for building work category licences will not generally hold current insurance under the Home Building Compensation
Fund or a certificate of eligibility to obtain such insurance from an approved insurer.
Consequently, new licences will be conditioned “ONLY FOR CONTRACTS NOT REQUIRING INSURANCE UNDER THE HOME BUILDING COMPENSATION FUND”.
This condition will be displayed on the public register. Licence holders with this condition can only contract for work up to $20,000.
The condition will be removed once Fair Trading is advised by the licensee or insurer that insurance or eligibility for insurance has been granted.
If however, you already hold eligibility for insurance under the Home Building Compensation Fund, please attach the relevant Certificate of Eligibility.
8. Insurance requirements under the Home Building Compensation Fund (Building Work Contractors Only)
9. Checklist
All applicants must complete and attach the relevant Checklist for Individuals based on the category(ies) of work being applied for.
Place an ‘X’ in the relevant box for the checklist(s) which you have completed as part of this application process:
Checklist for Individuals - General Building Work
Checklist for Individuals - Specialist Work
Checklist for Individuals - Other Building Work and Trade Work
10. Declaration and Photograph
Before you sign your declaration please note the following penalties for false or misleading statements:
Under s.307A of the Crimes Act 1900 a person is guilty of an offence if she/he makes a false or misleading statement in an application for an authority or
benefit. The penalty for false or misleading application is imprisonment for 2 years, or a fine of $22,000 or both.
Under s.43(1) of the Home Building Act 1989 the Commissioner may cancel a licence if it is later discovered that a licence holder misrepresented
information in their licence application.
Read and sign the declaration below and submit your application, supporting documents, POI documents and fee for assessment.
Please note: The photograph will be used to verify your identity and will be placed on your Fair Trading file.
(Enter full legal name in BLOCK letter)
I, ________________________________, the applicant for this licence/certificate hereby authorise:
Fair Trading to make necessary inquiries with any organisation or individual to verify any information provided in this application to establish my
identity and my eligibility for a licence or certificate
Fair Trading to publicise or pass to other governments and police agencies in other jurisdictions details of any lost or stolen document, to restrict
its illegal use
any organisation or individual to disclose relevant information to Fair Trading for these purposes
Fair Trading to make any inquiries and to receive and disclose any information which is relevant to the applicant’s initial and ongoing eligibility to
hold this licence/certificate.
I, ________________________________, the applicant for this licence/certificate understand that:
Enter full legal name in BLOCK letters
it is a criminal offence under the Crimes Act 1900 to deliberately make false or misleading statements
this application and the information provided in this form remains the property of the NSW Government
information will be placed on a register open to the public in accordance with the Home Building Act 1989 and available under the Government
Information (Public Access) Act 2009
failure to supply information required on this form may delay the processing of this application
I have a right to seek access to and correct any information I have supplied.
I declare that the statements made in this application are true
and correct.
Signature of Applicant
Date
Glue photo in the box below
_____________________
_____________________
The photo on the right is a true
likeness of:
Name of Applicant
Signature of Checking Officer
PAGE 4
HB001
07-2020
PAGE 5
I have sighted and confirmed the Proof of Identity documents against original documents submitted with the application form.
Name of Checking Officer
Signature of Checking Officer
Date
11. Proof of Identity check for Business use ONLY
• Applicants must present in person and provide ONE original, hard copy document from each list.
• Additional linking or address documents may need to be provided.
• Documents must be current (i.e. they must be valid at the time they are presented).
• Documents cannot be used twice (e.g. if an applicant presents a driver licence under List 1, it cannot be presented again under List 2).
A current Australian photo driver’s licence or other such equivalent current photo card issued by a State or Territory Government agency
A current Australian passport
An Australian electronic visa record supported by a foreign passport
A current Australian Immicard issued by the Department of Home Affairs
A current Convention Travel Document issued by the Department of Foreign Affairs and Trade
A current Certificate of Identity issued by the Department of Foreign Affairs and Trade
List 1 – Photo ID
A current Australian photo driver’s licence or other such equivalent current photo card issued by a State or Territory Government agency
A current Medicare Card
A current Australian Change of Name Certificate
A current Australian Marriage Certificate
A current Certificate of Identity issued by the Department of Foreign Affairs and Trade
List 2 – Use in the Community
A current Australian Birth Certificate
An Australian electronic visa record supported by a foreign passport
A current Australian Immicard issued by the Department of
Home Affairs
A current Australian Citizenship Certificate
List 3 – Commencement of identity
A current Australian Birth Certificate
A current Australian Change of Name Certificate
A current Australian Marriage Certificate
Linking
If you have changed your name, please provide ONE linking document
from the list below:
Utility bill (telephone, gas or electricity) up to 1 year old
A residential tenancy agreement up to 1 year old
A passbook or account statement from a bank, building society
or credit union up to 1 year old
Council, water rates or land valuation notice up to 1 year old
Address
If you have not already presented a document which shows your current residential address, please provide ONE address document from the list below:
Enter details of 'List 1' document provided:
Document type
POI List 1 document
Example: Australian Passport
Document number
Date of Issue
Expiry date
Place of Issue Original document
sighted by
(please print name)
Current insurance renewal for house, contents, vehicle,
boat up to 1 year old
Taxation notice of assessment up to 1 year old
An electoral enrolment card or the evidence of enrolment
up to 1 year old
HB001
07-2020
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APPLICATION FORM - INDIVIDUAL (Innovation and Science Australia)

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Completed 13 October 2020

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