OHS Form - Application Form As Accredited Person

LAB 398E
ANNEXURE 3
OCCUPATIONAL HEALTH AND SAFETY ACT 1993

REGULATION 9 OF THE ELECTRICAL INSTALLATION REGULATIONS 1992
APPLICATION FOR REGISTRATION AS AN ACCREDITED PERSON
The Department of Labour

Occupational Health and Safety
Private Bag X117
R75-00
Pretoria
0001 Affix revenue stamps here
Sir
I hereby apply in terms of regulation 9 to be registered as an electrical tester for single phase*/installation
electrician*/master installation electrician* and hereby declare that the particulars given hereunder are, to
the best of my knowledge and belief, correct. I further declare that I know of no reason why I should not be
regarded as being physically able to inspect and test installations.
* Delete whichever is not applicable.
I attach two photographs of myself as required by the chief inspector.
Yours faithfully
…………………………………………..………… ………………………………..………….…….
Signature Date
Notes:
(i) The applicant must also sign this form in the three spaces provided for specimen signatures at
the end of this form.
(ii) The chief inspector requires the submission of two clear identical unmounted photographs of
40mm by 30mm showing the face and shoulders of the applicant. One photograph shall be
certified on the back as follows:
I certify this to be a true photograph of ……………………………………………………………….………..
………………………………………………………………………………………………………….…………
………………………………………………………. ……………………………………………………..
Signature of Magistrate, Justice of the Peace or Date
“Commissioner of Oaths”
(The photographs required are similar to those required for passport and can be obtained from any
photograph who renders such a service.)
1) Surname (block letters)………………………………………………………………………………….
2) First names (block letters) ………………………………………………………………………………
3) Postal address …………………………………………………………..……Code…………………..
Telephone No. (W)..………………………………..(H)……………………..……….………………..
(Cell)…………………………………(Fax)……………………………………………
4) Date of birth …………………………………. Place of birth ………………………………..……….
5) Identity number (immigration permit number) ………………………………………………….……
KZN: LMIS&P - IOP

LAB 398E
ANNEXURE 3
6) Details Of training appropriate to installation work:
Note – Where paragraph (a) hereunder is applicable, applicant must submit with the application,
testimonials from employers stating the duration and nature of training.
(a) Training other than under a contract of apprenticeship in terms of the Apprenticeship Act, 1944 or
the Manpower Training Act, 1981, in a trade appropriate to installation work.
Name and address of employer From To
(b) Apprentice or training in terms of the Apprenticeship Act, 1944 or the Manpower Training Act,
1981, in a trade appropriate to installation work:
No. of contract ……………………………………. Trade in which trained …………………….
Name and address of employer From To
7. Details of practical experience, other than referred to in paragraph 6 (documentary proof, such as
certificates of service, to be submitted.
Capacity in which
Name and address of employer From To employed
8. Details of certificates or diplomas held. (If you have passed a qualifying trade test and subjects such
as Electricians, Electrical Trade Theory, Installation Rules, etc., this should be stated and proof
thereof submitted):
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
Note – if original documents are enclosed, the application should be forwarded by registered post.
True copies certified as correct by a magistrate, justice of the peace or commissioner of oaths will be
accepted.
SPECIMEN SIGNATURE OF APPLICANT
Note – The specimen signatures should be the normal signature of the applicant and should be
carefully completed. One specimen will be affixed to any certificate of registration that may be issued.
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KZN: LMIS&P - IOP

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LAB 398E

OCCUPATIONAL HEALTH AND SAFETY ACT 1993

APPLICATION FOR REGISTRATION AS AN ACCREDITED PERSON

The Department of Labour

* Delete whichever is not applicable.

I attach two photographs of myself as required by the chief inspector.

I certify this to be a true photograph of ……………………………………………………………….………..

1) Surname (block letters)………………………………………………………………………………….

2) First names (block letters) ………………………………………………………………………………

3) Postal address …………………………………………………………..……Code…………………..

Telephone No. (W)..………………………………..(H)……………………..……….………………..

4) Date of birth …………………………………. Place of birth ………………………………..……….

5) Identity number (immigration permit number) ………………………………………………….……

KZN: LMIS&P - IOP

6) Details Of training appropriate to installation work:

Name and address of employer From To

No. of contract ……………………………………. Trade in which trained …………………….

Name and address of employer From To

KZN: LMIS&P - IOP

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