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Occupational Health and Safety Act, 1993 (Act No. 85 of 1993)

Regulations

Driven Machinery Regulations, 2015

Annexure 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

 

Surname:

First names:

Date of birth:

Identity number:

Nationality:

Passport No. and country:

Email:

Country of normal residence:

ECSA registration:

Position held:

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

 

Period

No.

Dates (inclusive)

No. of years

and months

Employer

Post held

Type of work


From

To





1.







2.







3.







4.







5.







6.







7.







8.







9.







Total numbers of years and months:





Note: additional training beyond period 9 may be submitted on a separate sheet.

 

(ii)        Summary of training in relation to erection and maintenance of the type of lifting machines

 

Period

No.

Dates (inclusive)

No. of years

and months

Employer

Post held

Subjects and type of work


From

To





1.







2.







3.







4.







5.







6.







7.







8.







9.







Total numbers of years and months:





Note: additional training beyond period 9 may be submitted on a separate sheet.

 

(iii)        Qualifications

 

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 ......

 

 

..............................................................................

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

 

For office use only

 

Application  APPROVED/NOT APPROVED

 

Reasons for refusal:  ..............................................................................................................................................................

 

 

Signature:  ..................................................................................   Designation:  ...................................................................

 

Registration No:  ........................................................................

 

Date:  ........................................................................................