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Replacement Document Application Form

The document is an application form for replacing a lost, stolen, or damaged licence, registration or accreditation document issued under the Work Health and Safety Act 2020 and Work Health and Safety (General) Regulations 2022. It requests information about the applicant such as name, address, contact details. It also requires a description of the circumstances in which the original document was lost, stolen or damaged. The applicant must declare that the information provided is true and correct.

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Jo Frucknows
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30 views

Replacement Document Application Form

The document is an application form for replacing a lost, stolen, or damaged licence, registration or accreditation document issued under the Work Health and Safety Act 2020 and Work Health and Safety (General) Regulations 2022. It requests information about the applicant such as name, address, contact details. It also requires a description of the circumstances in which the original document was lost, stolen or damaged. The applicant must declare that the information provided is true and correct.

Uploaded by

Jo Frucknows
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

Application for replacement

Licence, Registration or
Accreditation document
Work Health and Safety Act 2020
Work Health and Safety (General) Regulations 2022

CREDIT CARD PAYMENT DETAILS


(Payment will appear as “WA Gov – DMIRS” on your bank statement)

Card Type Visa Mastercard (Only Visa and Mastercard accepted)

Card Number

Card Holder Please


print

Expiry Date I authorise the Department to deduct the current prescribed fee*

Signature / Authorisation Date

Cardholder’s contact phone number:

*Fees are reviewed annually and are subject to change without notice. Current application fees can be found on our website.

You may lodge your completed application:

In Person:
By Post: Department of Mines, Industry Regulation and
Licensing Services Safety
Department of Mines, Industry Regulation Level 1, Mason Bird Building
and Safety 303 Sevenoaks Street, Cannington
Locked Bag 100 Opening hours: 8.30am - 4.30pm, Monday to
EAST PERTH WA 6892 Friday
Enquiries: 1300 424 091

OFFICE USE ONLY

Licence/Accreditation
/Registration number
Entered Chart Description ☐ High Risk Work –
Replacement Licence
Audited Department Code

Total Fee $

A42224525 Page 1 of 3
1. Holder details
Licence, Registration or
Accreditation number
Type of Licence, Registration or
Accreditation

Replacing a document held by a Company (Body Corporate) - one registered Director of the
Company must complete this form

Registered Company name

Registered Director name

ACN – Australian Company Number

Trading Name (if applicable)


Company address Street address

Suburb Postcode

Postal address (if different to Postal address


business address)

Suburb Postcode

Mobile phone no. Phone no. (day)

Email

Replacing a document held by an Individual

Family name

Given name/s

Date of birth Place of birth


Residential Address Street address

Suburb Postcode

Postal address (if different to Postal address


residential address)

Suburb Postcode

Mobile phone no. Phone no. (day)

Email

A42224525 Page 2 of 3
2. Circumstances

You must provide a description of the circumstances in which the document was lost, stolen or damaged.

☐ Lost ☐ Stolen ☐ Damaged

3. Declaration
Section 268 of the Work Health and Safety Act 2020 provides for penalties of up to $12 500 for a person who
gives information that the person knows to be false or misleading in a material particular or omits any matter or
thing without which the information is misleading; or who provides a document that the person knows to be false
or misleading in a material particular. By signing this application form you declare that the information you have
provided in support of your application is true and correct.

Individual

Legal Name: _____________________________________________________________________________

Signature: ___________________________________________ Date: _______________________________

Director of the Company *one registered Director of the company must sign this declaration

Legal Name: _____________________________________________________________________________

Signature: ___________________________________________ Date: _______________________________

A42224525 Page 3 of 3

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