Change of Details

SAVE AS EMAIL PRINT
Work Health and Safety Act 2011 (WHS Act) –

Work Health and Safety Regulation 2017 (WHS Regulation)
NSW Explosives Act – NSW Explosives Regulation
CHANGE OF DETAILS – APPLICATION

GENC – 01 DECEMBER 2017
Complete this form to change an individual, Privacy compliance statement

registered business or trading name, the Information that you voluntarily provide in this form
residential, main or postal address or contact is collected by SafeWork NSW to assess and process
details for a licence, certificate or card issued by your application.
SafeWork NSW (the Regulator).
SafeWork NSW intends to use and disclose the
How to fill in this form information (including any personal information) you
have provided in the following ways:
Please type directly into the form. When complete,
save a copy before emailing or printing. 1. to exercise its functions under the Work Health and
Safety Act 2011, including to administer, monitor and
If completing by hand, please print clearly and
enforce compliance with that Act
mark box(es) with a tick where required.
2. to record your information on a licence register,
Certified copy means a photocopy of the original
parts of which will be published online
document that has been certified as a true copy
by a justice of the peace. The JP must provide, 3. to disclose your information to other state,
beneath the certification, their signature, the territory and the Commonwealth regulatory
date on which the certification was made, their authorities
JP registration number and the state in which 4. to educate about work health and safety and
they are registered contribute to external research about work health
and safety
For assistance call 13 10 50 5. as otherwise required or permitted by law,
Fees including for the purpose of prosecution
There is no fee associated with this form. SafeWork NSW has a Privacy Management Plan
which provides more detailed information about who
Lodgement instructions SafeWork NSW is, how to contact SafeWork NSW,
and how SafeWork NSW manages personal and
Email (preferred): [email protected]
health information in line with NSW privacy laws. A
Post: Customer Service Centre, SafeWork NSW, copy of the Privacy Management Plan is available at
Locked Bag 2906, Lisarow, NSW 2252. www.safework.nsw.gov.au.
Email or post the application – do not send more The Privacy Management Plan provides detailed
than once. information about how you may access or amend
personal information held about you by SafeWork
NSW.
SECTION 1. DETAILS TO BE CHANGED

Mark the appropriate boxes.
Individual, corporation, registered business or trading name

Postal address Main address Contact details
1/4
Change of details – application GENC – 01 December 2017
SECTION 2. LICENCE/CERTIFICATE/CARD TYPE AND DETAILS

Mark the appropriate boxes.
High risk work licence General construction induction card Explosives licence
Security clearance Asbestos or demolition licence
Please provide licence details:
Type of licence Licence number
SECTION 3. EXISTING DETAILS

SECTION 3.1 INDIVIDUAL
Title Family/Surname Other names
Given name Date of birth (DD/MM/YYYY)
SECTION 3.2 CORPORATION

Registered name Registered business (trading) name (if applicable)
ABN
SECTION 3.3 MAIN ADDRESS DETAILS

STREET ADDRESS (MUST NOT BE A PO BOX) POSTAL ADDRESS Same as main address
Unit number/Street number/Property number Unit number/Street number/Property number
(include Lot or DP number if applicable) (include Lot or DP/PO Box/GPO Box/Private Bag/Locked Bag)
Street name Street name
Suburb Suburb
State Postcode State Postcode
2/4
SECTION 4. NEW DETAILS

Only complete those sections where the details have changed.
SECTION 4.1 INDIVIDUAL

I have attached a certified copy of the marriage certificate issued by a Registry of Births, Deaths and
Marriages in Australia (if applicable).
I have attached a certified copy of the change of name certificate issued by a Registry of Births,
Deaths and Marriages in Australia (if applicable).
Title Family/Surname Daytime contact number
Given name Mobile number
Other names Email
SECTION 4.2 CORPORATION

Registered name Registered business (trading) name (if applicable)
ABN
SECTION 4.3 RESIDENTIAL/MAIN ADDRESS DETAILS

STREET ADDRESS (MUST NOT BE A PO BOX) POSTAL ADDRESS Same as main address
Unit number/Street number/Property number Unit number/Street number/Property number
(include Lot or DP number if applicable) (include Lot or DP/PO Box/GPO Box/Private Bag/Locked Bag)
Street name Street name
Suburb Suburb
State Postcode State Postcode
3/4
SECTION 5. APPLICANT’S DECLARATION

It is an offence under the WHS Act and Regulation and Explosives Act and Regulation for a person to
make a statement that the person knows to be false or misleading.
I understand and declare that:

• I have read the privacy compliance statement and consent to SafeWork NSW using my information
(including personal information) as outlined in that statement
• To the extent that I have provided personal information about another person, I have authority from
that person to complete and submit this application and to provide consent on that person’s behalf
• the information supplied in this application is true and correct to the best of my knowledge.
• I have authority from the registered business/corporation to complete and submit this application
(business/corporate applicants only).
Applicant’s signature Date (DD/MM/YYYY)
SECTION 6. CHECKLIST TO SUBMIT YOUR APPLICATION

Attached Document
Applicants who are requesting a change of name must provide either:
• certified copy of the marriage certificate issued by a Registry of Births, Deaths and
Marriages in Australia
• certified copy of the change of name certificate issued by a Registry of Birth, Deaths and
Marriages in Australia.
Return of licences/cards
Licences/cards containing old details must be returned to the Regulator within seven days of receipt of the
replacement to: Customer Service Centre, SafeWork NSW, Locked Bag 2906, Lisarow, NSW 2252.
Catalogue No. SW08163

© Copyright SafeWork NSW 1017 Locked Bag 2906, Lisarow, NSW 2252 | Phone 13 10 50
SafeWork NSW, 92–100 Donnison Street, Gosford, NSW 2250 Website www.safework.nsw.gov.au
4/4

Change of Details

Uploaded by

Copyright:

Available Formats

Change of Details

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Change of Details

Uploaded by

Copyright:

Available Formats

SAVE AS EMAIL PRINT

Work Health and Safety Act 2011 (WHS Act) –

CHANGE OF DETAILS – APPLICATION

Complete this form to change an individual, Privacy compliance statement

SECTION 1. DETAILS TO BE CHANGED

Individual, corporation, registered business or trading name

SECTION 2. LICENCE/CERTIFICATE/CARD TYPE AND DETAILS

SECTION 3. EXISTING DETAILS

Given name Date of birth (DD/MM/YYYY)

SECTION 3.2 CORPORATION

SECTION 3.3 MAIN ADDRESS DETAILS

Street name Street name

State Postcode State Postcode

SECTION 4. NEW DETAILS

SECTION 4.1 INDIVIDUAL

Title Family/Surname Daytime contact number

Given name Mobile number

Other names Email

SECTION 4.2 CORPORATION

SECTION 4.3 RESIDENTIAL/MAIN ADDRESS DETAILS

Street name Street name

State Postcode State Postcode

SECTION 5. APPLICANT’S DECLARATION

I understand and declare that:

SECTION 6. CHECKLIST TO SUBMIT YOUR APPLICATION

Catalogue No. SW08163

You might also like