This form is used to apply for an high risk work licence assessment report book.

Note: If a representative is collecting book(s) on behalf of an Assessor they must complete section 4.

Application fee: $20.00 inc GST

Office use only
Date Received:
Fee Received: $
Receipt no:
Received by (TBC staff name):

2

1.  Licence details
Assessor number: / Expiry:
2.  Assessor details
Surname:
Given name/s:
Residential address:
Suburb: / State: / Postcode:
Is your postal address the same as above? (If no, complete below) / Yes / No
Postal address:
Suburb: / State: / Postcode:
Work number: / Mobile number:
Email address:
3.  Book requirements
Number of books required:
Office use only
Assessment report books serial numbers issued:
4.  Assessor representative (if applicable)
Name and signature of representative who is authorised to collect books on behalf of High Risk Work Assessor.
Name of representative:
Signature of representative: / Date:
5.  Receiving book(s)
How do you wish to receive the book(s)? / Post / Collection
6.  Declaration of Assessor
The information in this application is true and correct to the best of my knowledge.
I consent to the Work Health Authority making enquiries and exchanging information with WHS regulators in other States, Territories or the Commonwealth regarding any matter relevant to this application.
Name of Assessor:
Signature of Assessor: / Date:
Checklist
Requirements
Application is complete and signed
Payment of application fee
Section 4 completed if being collected by Assessors representative
Copy of front and back of Assessor accreditation
Privacy statement
The Department of Attorney-General and Justice complies with the Information Privacy Principles scheduled to the Information Act.
Lodgement – Territory Business Centre
Incomplete applications cannot be processed and will be returned. Completed applications can be lodged in person, email or via post at a Territory Business Centre below:
Darwin
Darwin Corporate Park
Building 3
631 Stuart Highway, Berrimah / Katherine
Shop 1, Randazzo Building.
18 Katherine Terrace. / Tennant Creek
Shop 2, Barkly House
Cnr Davidson and Patterson Street. / Alice Springs
Ground Floor, The Green Well Building. 50 Bath Street
Phone address: 1800 193 111 / Email address:
Postal address: GPO Box 9800, Darwin, NT 0800
Payment details
Payment method
Cash - Territory Business Centre
Cheque - payable to RTM (Receiver to Territory Money)
Credit Card
Visa / MasterCard
Name on card:
Credit card number: / Expiry:
I hereby authorise the Territory Business Centre to debit the above credit card for the amount of
Signature of cardholder: / Date:

Application for an assessment report book – HRW Assessor (V1.0 – 11 July 2017) 2