CONSENT DECLARATION
Offce Use Only: Do not stamp this form Location of SNSW/GAC:
Application No: Date Lodged:
13 32 20 www.fairtrading.nsw.gov.au
NSW FAIR TRADING
HB026
07-2020
PAGE 1
NOMINATED QUALIFIED SUPERVISOR
1. Details of Nomination
This nomination relates to:
Updating an existing contractor licence or an application for a contractor licence
This form must be completed by:
the holder of a Qualified Supervisor Certificate or Endorsed Contractor Licence (Q), and
the holder of the Company or Partnership Contractor Licence for which the supervisor is being nominated.
Page 1 is for completion by a Director of a Company or a Member of a Partnership seeking to add a nominee
Page 2 is for completion by the nominee
Further information regarding nominated qualified supervisors is available on the Fair Trading website.
Complete the following:
I am a Director of the company that holds the contractor licence or I am a Member the partnership that holds the contractor licence.
I have also undertaken a licence check on the Public Register and declare the following:
My nominee holds a current endorsed company or partnership contractor licence or a qualified supervisor certificate
My nominee holds the same category of work the company or partnership holds or is applying for
I understand that it is my responsibility to notify Fair Trading within 7 days if the nominee ceases to be the nominated supervisor for my company or
partnership contractor licence.
I have provided true and correct information.
My nominee is seeking to be the supervisor for more than one OR My nominee is not seeking to be the supervisor for more
company or partnership contractor licence and I have completed than one company or partnership contractor licence
the Additional Details Form 6 with my nominee
Note: failure to complete all of the declaration can affect the processing of the nomination
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.
Name of Director or Member Signature Date:
2. Details of Company or Partnership Contractor Licence (to be completed by Director or Member)
Expiry Date
/ /
Licence Number
Name of company or partnership
Category of Work
(Note this applies to existing licence holders only)
/ /
Where this document is in connection with a new application for a licence, in accordance with section
12 of the Licensing and Registration (Uniform Procedures) Act 2002, this consent declaration and any
supporting attachments are taken to be part of the application form submitted by the applicant making
application for an authority under the Home Building Act 1989.
I also make the following declarations:
I understand that it is my responsibility to notify Fair Trading within 7 days if I cease to be the nominated supervisor for a contractor licence.
I understand that it is my responsibility to supervise the carrying out of all relevant work undertaken by the contractor licence.
I understand that it is my responsibility to be in control of the work and I could be found guilty of improper conduct if codes of practice, ordinances or
regulations are breached, if unsuitable materials are used or the work is not done with due care and skill.
I understand that the Public Register will reflect that I am the nominated supervisor for the contractor licence.
I have provided true and correct information.
Note: failure to complete all of the declaration can affect the processing of the nomination
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.
Name Signature Date:
/ /
3. Details of Nominated Qualified Supervisor (to be completed by nominee)
Name of Nominated Qualified Supervisor / Nominated Person (enter full legal name) Date Of Birth
/ /
Certificate/Licence Number
Category of Work (must match the Category of Work held or being applied for by the Company or Partnership)
If YES to the above, please supply
Your Driver's licence number from other state than NSW: Your ACT, QLD or VIC interstate authority licence number:
PAGE 2
Business address:
Postcode:
Business phone: Mobile phone:
Email:
Select one of the following:
I am an Employee or Director or Member of the partnership that holds the contractor licence.
Select one of the following:
I am not the nominated supervisor for an existing contractor licence OR
I am already a nominated supervisor for an existing company or partnership contractor licence and wish to hold the position of nominated supervisor for
more than one contractor licence. I believe there are special circumstances that would enable me to supervise the work for more than one licence and
accordingly I have attached a fully completed . Additional Details Form 6
Note: failure to provide an Additional Details Form 6 may result in the nomination not being acceptable.
OR
I am already nominated as the supervisor for an existing company or partnership contractor licence and WISH TO RESIGN as the nominated supervisor for
(insert licensee's name) which holds licence number (insert licence number)
Are you an Electrician applying to be the nominated supervisor under Yes NoAutomatic Mutual Recognition?
You must attach copies of both the interstate driver's licence and the interstate licence card or registration
HB026
07-2020
Driver Licence Number
State of Issue
Expiry Date
/ /
Preferred method of lodgement
Email to: HBLicensing@customerservice.nsw.gov.au
Lodge in person: at your local Service NSW.
For the location of your nearest Service NSW Service Centre, go to www.service.nsw.gov.au or telephone 13 77 88.
If any address or contact details for either the Company/Partnership or the Nominated Qualified Supervisor need to be updated, please do so by either:
completing and lodging a to accompany this formChange of address and other contact details form
calling Fair Trading on 13 32 20
Note: individual licence holders can also update their details online via www.service.nsw.gov.au
Updating details and Lodging this form
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