Application for the appointment of an authorised representative by lindayy


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									(Letterhead of state registered union or federally registered union if you do not have state

Industrial Registrar
Industrial Registry
GPO Box 373
Brisbane 4001

Dear Registrar

Re:    Application to the Industrial Registrar for the appointment of a person as an authorised
       representative under Section 90C of the Workplace Health and Safety Act 1995

In accordance with the registered Rules of the (insert state or federal registered union name), I
insert name, title and address of the office holder of the state or federal registered union who is
authorised to sign such applications. Note that this would usually be the union Secretary) wish to
apply for the appointment of (insert name and address of employee or office holder with the
state/federal registered union) as an authorised representative in accordance with Section 90C of the
Workplace Health and Safety Act 1995.

In accordance with section 90D, (insert full name of office holder or employee) is an
(employee/office holder) of the (insert state or federal registered union name) and has satisfactorily
completed approved training through attendance at the Course in Occupational health and Safety for
Authorised Representatives of Employee Organisations (or Course in Occupational Health and
Safety for Accredited Representatives for Employee Organisations) undertaken at the Safework
College of Workplace Health and Safety on (insert date/s).

A copy of the statement of completion of the course is attached.

Note that the Industrial Commission has not within the previous three years cancelled an
appointment of this person as an authorised representative.

Please find attached two recent passport sized photographs of the authorised representative, to
which the person to be appointed has signed on the reverse, which I affirm and declare are
photographs of the person to be appointed. Appearing below are genuine signatures of the person
to be appointed, for inclusion on the identity card in accordance with the requirements of section

Yours sincerely

(Signature of office holder authorised to make this application)
(insert name and title of the office holder of the state/federal registered union)

            Signature 1                                       Signature 2

Note: Not for inclusion in the letter but as a reminder
• Ensure signatures do not extend beyond the 4.5cm signature x 1.5 cm boundaries of the
  drawn box
• Securely attach photographs in a sealed envelope to this application. DO NOT staple
  through the photographs.
• Ensure the photographs are signed on their reverse by the person to be appointed

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