Licence To Perform High Risk Work Change Of Address Notification - Safework Sa
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1SafeWork SA
LICENCE TO PERFORM
GPO Box 465
FORM
HIGH RISK WORK
Adelaide, SA 5001
CA
Contact: 1300 365 255
CHANGE OF ADDRESS NOTIFICATION
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 3
DECLARATION
STEP 1
YOUR DETAILS
(Please record your name exactly as it appears on your photo
I declare that, to the best of my knowledge, the information
provided in and supporting this notification is true and
identification, eg Licence to Perform High Risk Work)
correct in every particular.
FAMILY NAME (as per your photo identification)
PRINT NAME
GIVEN NAME/S (as per your photo identification)
APPLICANT’S
SIGNATURE
GENDER
DATE OF BIRTH
DATE
/
/
STEP 4 – LODGEMENT INSTRUCTIONS
CONTACT TELEPHONE NUMBER/S
This form must be lodged with SafeWork SA by post,
Tel (
)
email or fax together with a copy of your photo ID. You
can do this via:
LICENCE TO PERFORM HIGH RISK WORK NO.
a) post to: SafeWork SA, High Risk Work Licensing
GPO Box 465, ADELAIDE 5001
(eg Driver’s Licence, Passport)
COPY OF PHOTO ID ATTACHED
b) e-mail to: highriskwork@safework.sa.gov.au
(providing you have scanned this form and any
If Driver’s Licence, please copy front & back of card
YES
attachments); or
A:
NEW RESIDENTIAL ADDRESS
If you have any questions about completing this form, please
telephone the SafeWork SA Help Centre on 1300 365 255 or
visit
Postcode
END OF NOTIFICATION
AS ABOVE
B:
NEW POSTAL ADDRESS
OFFICE USE ONLY:
Postcode
Help Centre Officer: .............................................................
Identity Established:
Yes
No
Mobile
Evidence Received:
Yes
No
Email
Signature Verified:
Yes
No
Details amended on InfoNet:
Yes
No
–
STEP 2
PREVIOUS ADDRESS DETAILS
Date: ...........................................
A:
PREVIOUS RESIDENTIAL ADDRESS
Licensing Officer: ..................................................................
Amendments Verified:
Yes
No
Postcode
Date: ...........................................
AS ABOVE
B:
PREVIOUS POSTAL ADDRESS
.......................................................................................
NOTES
................................................................................................
Postcode
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