Construction Occupation
Form for Appointing Nominee	

This approved form is to be used for the appointment of nominees under the Construction Occupations (Licensing) Act 2004. Please ensure that the nominee and a Director of the company or Partner of the partnership have signed the form. 

Privacy Information
The personal information on this form is provided to Access Canberra of the ACT Government to enable the processing of your application. If all or some of the personal information is not collected, Access Canberra cannot process your application. The personal information you provide may be disclosed to the other ACT Government Directorates, and third parties external to the ACT Government, as required by specific legislations administered by Access Canberra. The Information Privacy Policy Annex contains information in regard to what information Access Canberra collects and to whom it is disclosed. The policy also contains information about how you may access or seek to correct your personal information held by Access Canberra, and how you may complain about an alleged breach of the Territory Privacy Principles. The Information Privacy Policy can be found on the http://cmd.act.gov.au/legal/privacy_statement.  

Section A —Proposed Nominee Details
Title 		 Surname 									 

Given Names							Date of Birth				
Individual Licence						Expiry Date			

Mobile Number					Email						

Pursuant to section 28 of the Construction Occupations (Licensing) Act 2004 I agree to become the nominee 

for the company/partnership identified in part B. 

Signature of proposed nominee 						Date 			

  Section B — Nominee eligibility to be appointed  to Company / Partnership
Requirement:	To be eligible to be a nominee for a corporation the proposed nominee must be a Director of employee of the corporation. 

	OR

	To be eligible to be a nominee for a partnership the proposed nominee must be a partner in the partnership or a nominee of the corporation within the partnership. 

 Yes	— A historical company extract issued by the Australian Securities and Investment Commission needs to be provided to prove the proposed nominee is a Director, the licence details will need to be provided of a partnership to prove the proposed nominee is a partner or is the proposed nominee is an employee of a corporation then evidence of the employment relationship between the proposed nominee and the corporation must be provided.

 No  — please note that the proposed nominee may be ineligible to be appointed to the partnership/corporation licence.

	

Section C — Nominee declarations 
1.	I understand that I will remain the nominee of the company/partnership until such time as I become ineligible to stay a nominee if I cease to be licensed in a construction or occupation class appropriate for any of the construction services for which I as the nominee am responsible.

 Yes										 No

2.	I understand that as a nominee I am responsible for work undertaken on behalf of the company/partnership and that disciplinary action can be taken against my individual licence under the Construction Occupations (Licensing) Act 2004.

 Yes										 No

3.	I understand that if more than one nominee is appointed to the company/partnership I may wish to retain records that document the particular work I was responsible for on behalf of the company/partnership.

 Yes										 No 

4.	I understand that as a nominee I must be able to exercise the functions of a nominee on a daily basis.

 Yes										 No

5.	I understand that I can resign at any time from being a nominee for the company/partnership only with approval from the Construction Occupations Registrar.

 Yes										 No

6.	I understand that if I am a sole nominee for a company/partnership then the company/partnership will cease being a licensed entity if I resign; and that the Construction Occupations Registrar will write to the company/partnership informing them of my resignation.

 Yes										 No

7.	I understand that the company/partnership can revoke my appointment as a nominee only with approval by the Construction Occupations Registrar; and that the Construction Occupation Registrar will write to me informing me of the revocation of my appointment. 

 Yes										 No
Section D — Company / Partnership Details
As Director/Partner I agree to the appointment of the above licensee to be nominee for the Company/Partnership as referenced below.

Individual /Entity Name						ACN				

Construction Occupation				Construction Occupation Class			 

Director/Partner Name							

Signature of Director/Partner 						Date 			 

Section E — Payment Details
Upon lodgement of your application you will be required to pay a fee to appoint the new nominee.  This fee is $23.00.
If the appointment of a nominee changes the occupation or occupation class of the company/partnership, a fee for a replacement card will need to be paid.  This fee is $46.00.
Section E — Lodgement and Contact Information
Access Canberra Environment Planning and Land Shopfront
GPO Box 1908, Canberra City ACT 2601 
16 Challis Street, Dickson ACT 2602 
Business Hours: 8.30am to 4.30pm weekdays (excluding Public Holidays) 
Phone: (02) 6207 1923 
Email: epdcustomerservices@act.gov.au