ELEVATING WORK PLATFORM ASSOCIATION OF AUSTRALIA INC ABN 32 545 830 419 EWPA ACCREDITED TRAINER FORM AT RENEWAL: SECTION A & C MUST BE COMPLETED AT NEW APPLICANT: SECTION A, B & C MUST BE COMPLETED A. I wish to apply to the EWPA Inc to become an Accredited Trainer / Renew my AT Licence. Family Name: First Name: Home Address: Suburb: State: Post Code: Home Phone No: Home Fax No: Mobile No: Email: AN EWPA ACCREDITED TRAINER MUST BE A MEMBER OF THE ASSOCIATION EITHER DIRECTLY OR THROUGH A MEMBER COMPANY Member Company: Company Address: Suburb: State: Post Code: Company Phone No: Company Fax No: Company Mobile No: Company Email: IF RENEWING AT LICENCE PLEASE INSERT ACCREDITED TRAINER NUMBER: AT NUMBER: B. NEW APPLICANTS ONLY: Accredited Trainer Requirements: please complete details below and attach CERTIFIED COPIES of certificates and cards (front and back): QUALIFICATION Certificate No: / Licence No: (Certified copies required ) 1 TAA40104 CERTIFICATE IV IN TRAINING AND ASSESSMENT 2 TLILIL508A – NATIONAL CERTIFICATE OF COMPETENCY CLASS WP 3 CPCCCM1006A OR MNMG237A WORK SAFELY AT HEIGHTS 4 CPCCOHS1001A – WORK SAFELY IN THE CONSTRUCTION INDUSTRY (WHITE CARD) 5 SBE230 EWPA YELLOW CARD DUTY OF CARE TRAINING Skills Recognition (Recognised Prior Learning) Please summarise on a separate sheet qualifications or skills/experience that meets or exceeds the above AT requirements. C. Please include a passport sized photograph of the Applicant or email an image (in "Jpeg" format) to email@example.com Subject to the success of your application you will become an EWPA Accredited Trainer and will be registered as such under the EWPA / NMIT nationally recognised Training Program. An Accredited Trainer (AT) is authorised by the EWPA Inc to carry out training as per the EWPA program and issue “Trained Operator” Yellow Cards upon successful completion of the program by the Applicant. The AT Licence is issued for 3 years and incurs a fee of $300 – this includes a free listing on the www.ewpa.com.au webpage. Proof of Accredited Trainer status will be a nationally registered EWPA Inc “Accredited Trainer” Photo Licence which must be shown to Applicants as part of the Training Program. SIGNATURE I have read and accept the information provided on this form and the attached EWPA Accredited Trainer Licence Terms and Conditions. I hereby declare that all of the information provided by me herein is true and correct. Signed (Applicant): Date: Please return to EWPA Inc., PO Box 1304, Mona Vale, NSW 2103. Tel: 02 9997 5133 Fax: 02 9997 4485 Email: firstname.lastname@example.org Webpage: www.ewpa.com.au Issue 6: Jan 2010 ELEVATING WORK PLATFORM ASSOCIATION OF AUSTRALIA INC ABN 32 545 830 419 EWPA ACCREDITED TRAINER LICENCE TERMS AND CONDITIONS These terms and conditions are posted on www.ewpa.com.au and may be updated from time to time with notification to Accredited Trainers. Licensing by the Elevating Work Platform Association The Elevating Work Platform Association of Australia Inc (EWPA) is incorporated under the Associations Incorporation Act 1984 (NSW) and has the capacity under Section 17(3) to exercise its powers in other States. The EWPA issues Accredited Trainers’ licences to persons who have submitted the official application form together with the prescribed fee and who are accepted as meeting the skills and experience levels required by the EWPA. Licences are issued for the duration of three years. After acceptance as an EWPA Accredited Trainer the applicant is issued an Accredited Trainer Photo ID Licence and is thence qualified to carry out the required training to train personnel for the issue of an EWPA Trained Operator’s Card. It is a prerequisite that an Accredited Trainer is a member of the EWPA either directly or through a member company, however the licence issued is for the use of the applicant only and the applicant is personally responsible to both carry out the training and to maintain the appropriate documents such that all the relevant files are accessible by the Accredited Trainer and will be made available to the EWPA or the nominated auditor if required. The correct training of Operators for plant and equipment is a requirement under the Occupational Health and Safety Acts and Regulations in each State and Accredited Trainers must be familiar with the appropriate Occupational Health and Safety legislation and ensure that they maintain compliance. Accredited Trainer Licence Conditions The EWPA issues Trained Operator’s Cards under the following conditions which all Accredited Trainers are required to administer: 1 Training is to be carried out strictly in accordance with the Training Manual produced by the Northern Melbourne Institute of TAFE (NMIT) in association with the Elevating Work Platform Association of Australia Inc. 2 The elements laid out in the Training Manual under Section B list the procedures to be followed in order to meet the duty of care requirements of the OH and S Acts and Accredited Trainers are required to understand and comply with these procedures. 3 Accredited Trainers are to ensure that Trained Operator Application Forms are filled out legibly and are correct before forwarding them on to the EWPA. In particular Accredited Trainers must ensure that the boxes marked “EWP Type” are marked to indicate only those types relevant to the training given. White copies of the forms must be forwarded to the EWPA within 14 days (normally 10 working days) after the date of training to ensure compliance with the Training Manual Section B. 4 To ensure proper traceability of Trained Operator Application Forms, Accredited Trainers are to ensure that Trained Operator Application Pads are used in sequential order with no gaps in the sequence. To maintain the integrity of the system cancelled forms are also to be forwarded to the EWPA. 5 Trained Operator Forms are to be distributed and filed by Accredited Trainers personally in accordance with the Training Manual Section B. Forms must be filed numerically or be able to be retrieved numerically for the purpose of queries or audits. Breach of Licence Terms and Conditions The EWPA authorises Accredited Trainers issued with Photo ID Licences to carry out training in accordance with the Training Manual produced by the Northern Melbourne Institute of TAFE (NMIT) in association with the Elevating Work Platform Association of Australia Inc. The EWPA may suspend or cancel a licence for a breach of any of the licence terms and conditions. Non-compliance with the relevant Occupational Health and Safety legislation or breaches of local site safety rules are considered to be a breach of the EWPA Licence Terms and Conditions. Notification of a Breach of Licence Terms and Conditions Any purported breach of licence conditions will be subject to the following process: 1 The EWPA will contact the Accredited Trainer with notification of a breach of Licence Terms and Conditions by registered mail. 2 The EWPA will give the Accredited Trainer at least 14 days (normally 10 working days) within which to make submissions in relation to the breach. 3 The EWPA may suspend or cancel a licence if after considering all submissions it is satisfied that the Licence Terms and Conditions have been breached. Renewal of Licence Licence renewal forms will be sent to Accredited Trainers at least 30 days before the licence expiry date and must be completed and submitted to the EWPA no later than 14 days (normally 10 working days) prior to the licence expiry date. Change in circumstances Any change in circumstances relevant to the Accredited Trainer such as new telephone numbers, changed email or postal addresses or any change to membership details are to be notified to the EWPA within 30 days. Resolution of Disputes Disputes between Accredited Trainers and the EWPA are to be referred to a centre for mediation as agreed by the parties to the dispute or, failing agreement, as nominated by the President of the Law Society of New South Wales or their nominee.