1.

ENTITY DETAILS: Company Name

Section 1 to be completed by Managing Director/Member of entity

APPLICATION FORM FOR REGISTRATION AS A LIFTING MACHINE ENTITY

FOR DOL USE ONLY Record of Registration Registration Date Registration Number Name

NAME OF CEO/MD/MEMBER

CONTACT PERSON

Postal Address

Signature Designation

Physical Address

Company Registration Number VAT Number Tel No Fax No E-mail

Cell No

Section 2 to be completed by Lifting machine inspector staff directly responsible for the testing of lifting machines 2.a Personal Detail First Names:

2. COMPETENCY AND PROFICIENCY OF TECHNICAL STAFF

Surname:

Date of Birth:

Identity No:

Nationality:

Passport No.and Country:

Country of normal residence:

E-mail

Position held:

ECSA REGISTRATION

LMI No.:

Signature of Person Nominated Date:

2.b.1. Summary of Experience

Period No: 1 2 3 4 5 6 7 8 Total years, months: 9 From Dates (Inclusive) To

2.b Relevant Qualifications and Experience of Nominated Lifting Machinery Inspector

Number of Years and Months Employer Post Held Subject and type of work

Note: Additional experience beyond period 9 may be submitted on a separate sheet

2.b.2. Summary of Training

Period No: 1 2 3 4 5 6 7 8 Total years, months: 9 From Dates (Inclusive) To

Number of Years and Months

Employer

Post Held

Training courses attended

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

2.b.3. Highest Qualification

Qulification

Date obtained

Educational Institution

I, (full names) hereby accept the nomination as a Lifting Machine Inspector for this company. I solemnly declare that, to the best of my knowledge, all the information contained herein is true. Name Date : 3. EQUIPMENT: a. b. c. d. e. f. 'Signature:

Indicate list of minimum equipment available

4. SCOPE OF APPLICATION a. b. c. d. e. f.

List all lifting machine tested by the entity

5. ADDITIONAL INFORMATION REQUIRED 5.a. Certified copies of qualifications 5.b. Calibration certificate of testing equipments and instruments 5.c. Copy of test certificate for each type of lifting equipment 5.e. Summary of the auditable system of work performed 5.f. Copy of training program for technical staff 5.d. Copy of a company code of conduct for Technical staff in relation to OSHACT

5.g. Summary of inspection method for each type of lifting equipment including relevant national standards 3. DECLARATION BY MANAGING DIRECTOR / MEMBER OF ENTITY

I, .. (full names) hereby apply for registration of .... (Company) as a Lifting Machine Entity. I solemnly declare that, to the best of my knowledge, all the information contained herein is true. 'Signature: Sworn to / Affirmed before me at on this the day of Commissioner of Oaths / Justice of Peace: (month and year) (Commissioner's stamp)

Please Post your application form to: Chief Inspector,Department of Labour Private Bag x 117 PRETORIA 0001. Laboria Hoouse,215 Schoeman Street, Pretoria 0001