OFFICE
ONLY
CRN: Licence No:
Receipt Amount $ . Receipt No:
COMPLETING THIS FORM
Use BLACK pen only
Print clearly in BLOCK LETTERS
DO NOT use correction fluid – any amendments should be
crossed out and initialled
Return your fully completed form and ALL required documentsby:
Post: GPO Box 5099 Brisbane QLD 4001
in person: QBCC Service Centres are listed on our website
Email: info@qbcc.qld.gov.au
(all required documents must be scanned and attached)
Online: Lodge via myqbcc
Initial licence application fee 617.30
this consists of an application fee
(411.95) and a licence fee (205.35)
Licence restoration fee 617.30
this consists of an application fee
(411.95) and a licence fee (205.30)
1. APPLICANT DETAILS
2. APPLICATION TYPE AND FEES
GOVERNING LEGISLATION
This form is to be used for the purposes of sections 246BN and 246BR of the Building Act 1975. The Queensland Building and Construction
Commission will consider the information in this form when deciding the suitability of a person applying for a licence or restoration.
Renewal and application fees are set by the Building Regulation 2006 Please tick
3. SERVICE AREAS (local government areas in which you intend to provide a service)
Surname
First names
Business name
ABN
Address
Suburb
State
Phone
Mobile
Email
Fax
Postcode
Date of birth
Title Mr Mrs Miss Ms Other
D D M M Y Y Y Y
/ /
00044_F27PSI_07/20
Page 1 of 6
FORM 27
APPLICATION FOR POOL SAFETY INSPECTOR LICENCE
Certificate of competency for approved training course (not required for licensed building certifiers)
Evidence of passing pool safety inspector test (not required for licensed building certifiers)
*
Passport style photograph (see requirements on page )
Other (eg  card)
True False
I have not been convicted of an oence under the Building Act or another relevant Act such as an Act
dealing with swimming pool safety building or occupational licensing
I have not been convicted of an oence that involves fraud or dishonesty
I have not previously been refused a licence or had a licence suspended or cancelled under the Building Act
 or another Act
I have not under another Act been disqualified from holding a licence under that Act
I have not accumulated demerit points prescribed under the Building Regulation  for section CG()
(d) of the Building Act 
I have not been involved in dealings where the standard of honesty and integrity exhibited was less than
would be expected of a pool safety inspector
If I have answered ‘false’ to any of the above I provide the following explanatory information
4. PR
OOF OF IDENTITY
Please provide a full colour certified copy of the one of the following:
5. ATTACHMENTS
6. DECLARATION - (your signature in section 9 confirms this declaration)
Passport Driver license
NOTE This is not compulsory to answer this question You may attach more information if necessary
* Not compulsory requests for cards submitted with no photo will be issued with a blank silhouette
00044_F27PSI_07/20
Page 2 of 6
FORM 27
APPLICATION FOR POOL SAFETY INSPECTOR LICENCE
7. PROFESSIONAL INDEMNITY DECLARATION
I am the insured or the principal of the insured companybusiness listed on the Schedule of Insurance/Certificate of currency
attached I have or the companybusiness has professional indemnity insurance that provides the following
a A minimum limit of indemnity of 
(must be a minimum of  million) for any one period of insurance that may arise from the performance by the pool safety
inspector of a pool safety inspection function
b An insurance period of
M M Y Y Y Y
/
to
M M Y Y Y Y
/
c As well as the limit under a) above cover for costs and expenses (not limited to an amount less than ) incurred
with the consent of the insurer in defending or settling a claim
d No exclusion or special limitation for personal injury or property damage provided that the claim arises from an actual
or alleged breach of professional duty
e No requirement for any particular disclaimer to be given by the pool safety inspector to the pool safety inspector’s
clients or customers before during or after the performance of the pool safety inspection functions
f Indemnity for breaches of professional duty as a pool safety inspector arising from an act error or omission of the
inspector after the day the inspector became a pool safety inspector
g At least one automatic reinstatement of indemnity
h Indemnity for negligent performance of a pool safety inspection function (other than for claims for fraudulent or illegal
acts or omissions)
i Indemnity for former principals partners and directors of the employer of the pool safety inspector who were but
no longer are pool safety inspectors and
j Provides cover for the following pool safety inspectors listed under Schedule A below
Signature of
insured party
Date
Name of insured
Policy number
Current to
Insurer underwriter
D D M M Y Y Y Y
/ /
SCHEDULE A (To be completed only where the insured is a company/business with nominated employee inspectors. Not for use by sole operators).
IDENTIFY POOL SAFETY INSPECTORS COVERED BY PROFESSIONAL INDEMNITY INSURANCE POLICY
D D M M Y Y Y Y
/ /
Pool safety inspector
Pool safety inspector
Pool safety inspector
Pool safety inspector
Pool safety inspector
*Sole operator or principal of companybusiness
00044_F27PSI_07/20
Page 3 of 6
FORM 27
APPLICATION FOR POOL SAFETY INSPECTOR LICENCE
PRIVACY NOTICE: The QBCC is collecting information on this form to determine whether you are entitled to a licence or monitoring compliance for your
existing licence. This is authorised by the Building Act 1975. Some of this information collected will be included in the Public inspector directory on the QBCC
website. You may receive some related information from us for the purposes of marketing and communications. You will be able to opt-out/unsubscribe to
receiving this information. Please refer to our Privacy Policy for full use and disclosure details. All information held by the QBCC may be subject to application
for access under the Right to Information Act 2009 (RTI Act).
I declare
the information contained in and accompanying this form is true and correct
I have read the Privacy Notice (below)
8. DECLARATION BY THE APPLICANT
00044_F27PSI_07/20
FORM 27
APPLICATION FOR POOL SAFETY INSPECTOR LICENCE
Page 4 of 6
Applicant’s
signature
Date
Name
D D M M Y Y Y Y
/ /
9. PAYMENT OPTIONS
I will pay at a QBCC oce
Cheque or money order payable to Queensland Building and Construction Commission
Credit card
Name of Card Holder
Credit card number
Expiry Date
Total Amount $
.
GST Requirements
The Commission’s licence and application fees are exempt from GS
T
M M Y Y Y Y
/
The Queensland Building and Construction Commission manages
personal information in line with the Information Privacy Act 2009.
This Privacy Policy describes the personal information that may
be collected and used by the QBCC. We collect and manage your
personal information from you when you:
complete and submit a form electronically or by mail
you deal with us over the telephone or counter
you register for My QBCC
email us
provide us with feedback
ask us to contact you, and you consent to us collecting, storing,
using, maintaining and disclosing your personal information.
INFORMATION WE MAY REQUEST
We may ask you to provide personal information if you submit
feedback to QBCC or lodge a form, electronically or otherwise.
We will only do this:
to meet your needs (e.g. answer a question)
to meet our needs (e.g. demographic analysis,
updatingourrecords)
if required by law.
DISCLOSURE OF PERSONAL INFORMATION
If you have submitted an application or complaint, we may provide
allor some of this information (if applicable) to your:
contractor/client
members of our panel of technical consultants (includes licensed
contractors, registered engineers, and industry specialists)
rectifying builders
external legal consultants
external financial consultants
reinsurers/actuaries.
We may also disclose your personal information to third parties,
including advisors and consultants and with third party service
providers we use in connection with conducting our business and
always subject to confidentiality provisions we deem appropriate.
Some of the third parties to whom we disclose your personal
information may be located outside Australia. For example, we may
disclose your personal information to external facilities in the course
of data processing services from third parties.
The countries in which these third parties are located will depend on
the circumstances. However, in the course of our ordinary business
operations we commonly disclose personal information to third parties
located in the United States of America.
We will not give your personal information to third parties without your
consent, unless as set out above or required by law.
ACCESS TO PERSONAL INFORMATION
If you would like to access any of your personal information that is
held by QBCC you can make an Information Privacy application.
AMENDING YOUR PERSONAL INFORMATION
You may apply to amend documents containing your personal
information held by QBCC, where you believe relevant information is
inaccurate, misleading, out of date or incomplete.
MAKING A PRIVACY COMPLAINT
If you believe there has been a breach of your personal information
involving QBCC you may lodge a privacy complaint.
RIGHT TO INFORMATION
All information held by the QBCC may be subject to application for
access under the Right to Information Act 2009 (RTI Act).
MORE INFORMATION
Email us if you would like to know more about information privacy
or visit the guidelines for community members on the website of
the Oce of the Information Commissioner Queensland.
00044_F27PSI_07/20
Page 5 of 6
PRIVACY POLICY
LICENCE PHOTOGRAPH GUIDELINES
Subject
Eyes open and clearly visible
Neutral expression
Mouth closed
Subject centred and facing the camera
Whole face visible
No hair or head covering across the face
No glasses
No smiling (sorry)
Facial piercings such as nose rings and studs
that are worn permanently by the subject must
not cause a reflection
Lighting
Even shadowless lighting on the face
White or light grey background preferable
No shadows on background
Light to ensure no red-eye
Editing
Final image must be a true likeness of the subject
No retouching of photographs permitted
Adjust brightnesscontrast only
Moles wrinkles scars must not be removed
Must not remove red-eye by editing
Image scale and specifications
Print size mm wide x  mm high
If scanned image is provided - photo must be high
resolution (min dpiRGB) in JPEG TIFF PNG or
PDF formats
Image height: 45-50mm
Image width: 35-40mm
Subject
min height
Subject
max height
36mm
32mm
04/10/19 15373229
POOL SAFETY INSPECTOR
LICENCE
JOHN CITIZEN-SMITH
Expires
110 Rodboro Street
Berserker Qld 4701
Licence Number
00044_F27PSI_07/20
Page 6 of 6
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