Medicines and Related Substances Act, 1965
R 385
Occupational Health and Safety Act, 1993 (Act No. 85 of 1993)RegulationsDriven Machinery Regulations, 2015Annexure A : Application form for registration as a lifting machinery entity |
Annexure A
APPLICATION FORM FOR REGISTRATION AS A LIFTING MACHINERY ENTITY
Section 1 to be completed by Chief Executive Officer/Managing Director/Member of Entity
1. ENTITY DETAILS
Company name:
Name of CEO/MD/member:
Contact person:
Postal address:
Physical address:
Company registration number:
VAT number:
Telephone No.:
Fax No.:
Cell No.:
Email address:
2. COMPETENCY AND PROFICIENCY OF TECHNICAL STAFF
Section 2 to be completed by lifting machinery inspector directly responsible for the testing of lifting machines.
(a) Personal details
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Surname: |
First names: |
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Date of birth: |
Identity number: |
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Nationality: |
Passport No. and country: |
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Email: |
Country of normal residence: |
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ECSA registration: |
Position held: |
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LMI No.: |
Signature of person nominated: ..........................................................................................................................
Date: ............................................................................
(b) Relevant qualifications and experience of nominated lifting machinery inspector
(i) Summary of experience in relation to erection and maintenance of the type of lifting machines
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Period No. |
Dates (inclusive) |
No. of years and months |
Employer |
Post held |
Type of work |
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Total numbers of years and months: |
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Note: additional training beyond period 9 may be submitted on a separate sheet. |
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(ii) Summary of training in relation to erection and maintenance of the type of lifting machines
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Period No. |
Dates (inclusive) |
No. of years and months |
Employer |
Post held |
Subjects and type of work |
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9. |
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Total numbers of years and months: |
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Note: additional training beyond period 9 may be submitted on a separate sheet. |
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(iii) Qualifications
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Highest qualification |
Date obtained |
Educational Institution |
I, ................................................................................................... (full name) hereby accept the nomination as lifting machinery inspector for this company. I solemnly swear/declare that, to the best of my knowledge, all the information herein is true.
Name: .................................................................. Signature: .....................................................
Date: ..................................................................
3. Scope of application
List all lifting machines tested by the entity/your company:
(a) ...............................................................................
(b) ...............................................................................
(c) ...............................................................................
(d) ...............................................................................
(e) ...............................................................................
(f) ...............................................................................
4. Equipment/Instruments
Indicate minimum equipment/instruments available:
(a) ...............................................................................
(b) ...............................................................................
(c) ...............................................................................
(d) ...............................................................................
(e) ...............................................................................
(f) ...............................................................................
5. Additional information required:
| (a) | Certified copies of qualifications |
| (b) | Calibration certificates of testing equipment and/or instruments |
| (c) | Copy of test certificate for each type of lifting machine |
| (d) | Copy of company code of conduct for technical staff in relation to OHS Act. |
| (e) | Summary of auditable system of tests carried out. |
| (f) | Copy of training program for technical staff. |
| (g) | Summary of inspection method for each type of lifting machine including relevant national standards. |
6. Declaration by Chief Executive Officer/Managing Director/Member of Entity
I, ...............................................................................................................................(full name) hereby apply for registration of .............................................. (company name) as a lifting machinery entity. I solemnly swear/declare that, to the best of my knowledge, all the information contained herein is true.
Signature: .........................................................................................
Sworn to/Affirmed before me at ............................................ on this ........................ day of .............................. 20 ......
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Commissioner of Oaths (Commissioner's stamp)
Please post your application form to: Chief Inspector, Department of Labour, Private Bag X117, Pretoria, 0001
Physical address: Laboria House, 215 Francis Baard Street, Pretoria, 0001
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For office use only
Application APPROVED/NOT APPROVED
Reasons for refusal: ..............................................................................................................................................................
Signature: .................................................................................. Designation: ...................................................................
Registration No: ........................................................................
Date: ........................................................................................ |
