Roads and Maritime Services (formerly RTA) photo card Identification card issued to a public employee Identification card issued by the Commonwealth, a State or Territory government as evidence of the person's entitlement to a financial benefit Declaration I declare that: to the best of my knowledge, the information provided in this form and any attachment(s) to this form, is true and correct in every detail. I consent to the Department of Planning and Environment disclosing my personal information to the Mining and Petroleum Competence Board and any people engaged for the purposes of managing practising certificates under the Work Health and Safety (Mines and Petroleum Sites) Act 2013 and the Work Health and Safety (Mines and Petroleum Sites) Regulation 2014. Name Position/title Contact telephone Mobile Signature Date Note: Giving false or misleading information is a serious offence under section 268 of the Work Health and Safety Act 2011, and Part 5A of the Crimes Act 1900. Clause 144 of the Work Health and Safety (Mines and Petroleum Sites) Regulation 2014 provides for the cancellation of a practising certificate on a number of grounds, including if the certificate was improperly obtained on the basis of false or misleading information. Checklist To avoid delays in processing your notification use this checklist to ensure you have completed all requirements. Have you:
Roads and Maritime Services (formerly RTA) photo card Identification card issued to a public employee Identification card issued by the Commonwealth, a State or Territory government as evidence of the person's entitlement to a financial benefit Declaration I declare that: to the best of my knowledge, the information provided in this form and any attachment(s) to this form, is true and correct in every detail. I consent to the Department of Planning and Environment disclosing my personal information to the Mining and Petroleum Competence Board and any people engaged for the purposes of managing practising certificates under the Work Health and Safety (Mines and Petroleum Sites) Act 2013 and the Work Health and Safety (Mines and Petroleum Sites) Regulation 2014. Name Position/title Contact telephone Mobile Signature Date Note: Giving false or misleading information is a serious offence under section 268 of the Work Health and Safety Act 2011, and Part 5A of the Crimes Act 1900. Clause 144 of the Work Health and Safety (Mines and Petroleum Sites) Regulation 2014 provides for the cancellation of a practising certificate on a number of grounds, including if the certificate was improperly obtained on the basis of false or misleading information. Checklist To avoid delays in processing your notification use this checklist to ensure you have completed all requirements. Have you:
Practising-certificate-notification-of-change-of-contact-details-or-place-of-work.docx