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					                                                           Plumbing Industry Commission
                                                        Application for Renewal of Registration



Name & Address: ............................................................................................. Home: .................................................
                                                                                                                           Mobile Phone:.....................................
.......................................................................................................................... Fax number: ........................................
                                                                                                                           Business Phone: ..................................
.......................................................................................................................... Date of Birth: ......................................

Business and/or Email Address: ....................................................................................................................................

I apply for the renewal of my Registration, number ....................... , which expires at 4 pm on .................... in the
classes of:



You are required under section 221ZB of the Building Act 1993 to state, since your last application for a registration
or application for renewal, whether you have (please circle):

1.      Been convicted of any offence involving fraud, dishonesty, drug trafficking                                                      YES                      NO
        or violence that was punishable by imprisonment for 6 months or more

2.      Been convicted of an offence under any law regulating plumbing work or                                                           YES                      NO
        specialised plumbing work

3.      Had your authorisation to carry out plumbing work or specialised plumbing                                                        YES                      NO
        work suspended or cancelled for any reason other than your failure to renew
        that authorisation

4.      Become an insolvent under administration                                                                                         YES                      NO

5.      Been convicted of an offence against section 12, 16, 17, 18, 20 or 22 of the
        Fair Trading Act 1985 or section 53, 55, 55A, 56, 58 or 60 of the Trade Practices                                                YES                      NO
        Act 1974 of the Commonwealth

                         If you answer YES to any of the above questions, please give details in a separate attachment.

I declare that the information provided in this application is true and correct and I consent to enquiries being made into any
information I have provided herein for the purposes of verification.




SIGNATURE:______________________________________________ DATE:______/______/______
Note:        Section 221ZZZG(1)(a) of the Building Act 1993 provides that obtaining a registration or licence by way of fraud, misrepresentation or concealment of
             the facts in the information provided to the Commission, is a proper cause for disciplinary action.

             Section 221V of the Building Act 1993 provides that it is an offence to give information in this application that you know, or ought to reasonably know,
             is false.


The Commission must receive your renewal BEFORE 4PM on the day your current registration expires. This expiry
date is shown on your registration card. If the Commission does not receive your renewal by this date, your registration will
lapse and it will be illegal for you to perform plumbing work within the state of Victoria.

A person who is registered may undertake relevant work – but must do so under the supervision of a licensed person. The work of
a registered person must be certified by a licensed person.

                                                                                      PTO


8b7325ba-fc84-4537-948e-a338d6689cad.doc 1/7/06
      TAX INVOICE - ABN: 41 303 392 815

     Name: .....................................................................................................................................

     Address: ..................................................................................................................................

      ......................................................................................... Registration No............................

     AMOUNT OF PAYMENT

             (A) If you hold registration(s) only.                                                         Reg Fee               GST                 Total Reg Fee
             3 Year Registration Fee                                                                       $255.00                $0.00                     $255.00
     OR

             (B) If you hold licence(s) as well as registration(s).                                        Reg Fee               GST                 Total Reg Fee
             (Your registration fee is included in your licence fee. Your
             registration will lapse if your licence lapses)
             3 Year Registration Fee                                                                           $0.00                $0.00                       $0.00
     OR

             (C) If you hold a reduced registration(s) only.                                               Reg Fee               GST                 Total Reg Fee
             (You will not be working for payment or reward, and have
             signed the declaration below)
             3 Year Registration Fee                                                                         $85.00                 $0.00                     $85.00
       I hereby declare that I am currently not practising plumbing work for payment or reward in the State of Victoria. If this situation
       changes, I will immediately advise the Plumbing Industry Commission in writing.



     SIGNATURE:_________________________________________________         DATE: ______/______/______
                       sign here only if (C) above applies to you
     _________________________________________________________________________________________________
     METHOD OF PAYMENT:

      Payment by Cheque or Money Order:                                   Cheques should be payable to ‘Plumbing Industry Commission’

     OR

     Payment by Credit Card:

     CREDIT CARD DETAILS


     TYPE OF CARD:                                     BANKCARD                                     MASTERCARD                               VISA

     EXPIRY DATE:_________/_________                                      AMOUNT: $255.00 or $85.00 (circle whichever is applicable)

     SIGNATURE:________________________________________________                                                          DATE:_______/______/______

     CARD HOLDER'S NAME: _________________________________________________________________
     ________________________________________________________________________________________
     This form to be returned to one of the following addresses (with relevant fee) so that your new Registration Card may be issued

      MELBOURNE                         BALLARAT                             BENDIGO                              SALE                             WANGARATTA
      450 Burke Road                    2 Skipton Street                     46 Breen Street                      317 York Street                  1 White Street
      Camberwell VIC 3124               Ballarat VIC 3350                    Bendigo VIC 3550                     Sale VIC 3850                    Wangaratta VIC 3677
      PO Box 552                        PO Box 87                            PO Box 2169                          PO Box 893                       PO Box 1100
      Camberwell 3124                   Ballarat VIC 3353                    Bendigo VIC 3552                     Sale VIC 3853                    Wangaratta VIC 3676
      Ph. 03 9889 2211                  Ph. 03 5333 4804                     Ph. 03 5441 7830                     Ph 03 5143 3021                  Ph: 03 5721 3400
      Fax: 03 9889 3633                 Fax: 03 5333 4817                    Fax: 03 5442 7845                    Fax: 03 5143 3027                Fax: 03 5722 9074
      Office Hours:
      8.15 am to 4.45pm                 8.15 am to 4.30pm                    10 am to 2 pm                        10 am to 2 pm                    10 am to 2 pm
      Monday to Friday                  Monday to Friday                     Monday to Friday                     Monday to Friday                 Monday to Friday

Privacy: The Plumbing Industry Commission recognises the importance of protecting your privacy. The Commission is committed to the requirements of the
Information Privacy Act 2000. A copy of the Commission’s Privacy Policy is available on the Commission’s website at www.pic.vic.gov.au or from any office of
the Commission. Further information regarding the Privacy Act 2000 is available from the Victorian Privacy Commissioner at www.privacy.vic.gov.au

				
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