aplikacja CSCSprofessionalista.pdf

Authorisation code

CSCS SMARTCARD APPLICATION FORM

Card for Professionally Qualified Persons

(See reverse of form for use)

SECTION A - you, the applicant, must complete this section. Fill in any blank areas and tick the correct boxes

using black ink. Please keep within the white boxes.

A1 Your details:

CSCS Registration No.

Title

Surname

National Insurance No.

Forename

Home

Address

ATTACH

PHOTOGRAPH

HERE

Date of Birth

YYYY

Home/Work Telephone Number

Postcode

Mobile Number

E-mail

address:

Professional Institution/

Membership Grade

Professional

Institution Reg. No.

A2 Current Job Title

A3 I confirm that I meet: current CSCS Health & Safety requirements yes

(We do not require a copy of your Health and Safety Test

pass letter as this is stored on our database).

A4 Send my card to: my home address address in section B

a different address, which is:

Postcode

A5 I confirm to the best of my knowledge the information above is correct and I agree to comply with the CSCS Scheme rules as laid

out in the CSCS Scheme booklet. I understand and agree that the information on this form will be used by ConstructionSkills for the

purposes of administering the CSCS Scheme, this may include passing on information to Employers or Training Providers and for

this purpose, your data may be entered onto a secure database accessible via a website.

Please note that all application fees are non-refundable. If your application is incomplete you will be given 90 days to resolve any

issues. Any applications returned after 90 days will be subject to an additional £30.00 non-refundable application fee.

We may contact you by mail, telephone or e-mail to let you know about other goods or services or promotions

which may be of interest to you. Please tick this box if you wish to receive such information from us.

A6 I am the applicant and I confirm that the details in section A of this form, are to the best of my knowledge, correct and in line with

the Scheme rules.

Your signature:

Date:

YYYY

Please send a VAT receipt

SECTION B - This section needs to be completed by a current member of the applicant's Professional Institution,

whose membership is equal to, or higher than the applicant's above. The applicant must not sign this section.

B1 I confirm that the applicant meets the Scheme requirements listed at points 1 - 3 on the reverse of the form.

E-mail

address:

Address:

Print forename:

Print surname:

Professional Institution

Postcode

Membership Grade

Telephone:

Professional Institution Reg. No.

Signature

Date

YYYY

Form number: CSCS/PQP/05/10

Important Notes

This form is in two sections. Please read these notes carefully to ensure that the form is not

rejected.

Section A must be completed by the applicant.

Please fully complete section A1, including your Professional Institution Membership Grade

and membership number. A list of acceptable institutions and competence-assessed

membership grades can be found on the CSCS website www.cscs.uk.com (For those who

are members of the Architects Registration Board (ARB), please insert your ARB number.)

Section A2 - Please insert your Job Title (PLEASE NOTE THIS WILL NOT BE SHOWN

ON YOUR CARD).

Section B must be completed by a verifier.

The Verifier confirms that the applicant:

1 Is a member of an approved professional institution whose membership is at an

eligible competence-assessed grade.

2 Has taken the ConstructionSkills Managerial and Professional Health and Safety

Test.

3 Has continuing professional development records for the last two years relevant to

the job title listed overleaf.

Before sending your form please check that it has been fully completed. Your form will be

sent back if it has not been properly filled in.

IF YOU HAVE NOT ALREADY DONE SO RING 0844 576 8777 TO FIND OUT HOW YOU

CAN GET A FASTER SERVICE.

Payment - either:

• Enclosed payment of £30.00 by cheque or postal order - cheques should be made

payable to ConstructionSkills or

• If you have pre-paid for your application form enter the authorisation code you were

given (see box in top right hand corner of front of this form)

CSCS, PO Box 114, Bircham Newton, King's Lynn, Norfolk, PE31 6XD

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