Regulations > Driven Machinery Regulations, 2015 > Driven Machinery Regulations, 2015 : Notice No. R. 540 of 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) ...............................................................................

(d) ...............................................................................

(e) ...............................................................................

(f) ...............................................................................

4. Equipment/Instruments

Indicate minimum equipment/instruments available:

(a) ...............................................................................

(b) ...............................................................................

(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: ........................................................................................

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