The purpose of this statement is to accurately verify an individual’s building work experience. 

Verifier Details

Title 		 Surname 									 

Given Names							 Date of Birth	    /	  /	

Licence Number			State Licence is Held			 

Company Licence					Director/Nominee			

Phone Number (Business Hours) 				Preferred Time to be Contacted 		

Email*						

I understand that I must be available to take Access Canberra’s call to verify statements made in this form

 I have read and understand the above statement.

Competent Verifier 

All building work experience provided by an applicant for a licence must be independently verified by a competent person as defined by the Mandatory Qualification Schedule. This means verification by a licensed builder who was responsible for the supervision of the building work experience being undertaken by the applicant. The verification must attest to the extent, quality, relevance and recency of the building work undertaken. The verification must detail the experience including confirming the number of hours and the type of building work experience undertaken.

You must be/have been licensed for the duration of the project you are verifying. If you are employed by a licensed company and are verifying the applicant’s experience in the capacity as a nominee, the company must be/have been licensed for the duration of the project and your association with the company verified.

 I have read and understand the above statements. 

Applicant Details
Surname 									 

Given Name											 
 
Nature of Professional Relationship to Applicant							

Company Name in which the Applicant Worked With You 						 

Project Details
For any projects that you will be verifying you must record them below individually and have signed the applicant’s statements of building work experience for each project.
Block	Section	Suburb	Building Code of Australia Class	Number of storeys	

					

					

					

					

Verifier Questionnaire
The following information will be used by the Registrar to determine if you are a competent person to verify the applicant’s experience. 

1.	Do you hold a licence in another state?

  Yes - Provide further details below                                                                                        No
	State/Territory/Country ___________________________Expiry date:   ______/______/______  
2.	Is your licence (in any state) currently or has it previously been cancelled in Australia or overseas?
 Yes — you must attach details     							 No 
3.	Have you previously had a builder licence cancelled, refused or suspended in Australia or overseas?      

 Yes — you must provide comprehensive details in an attachment to this statement	 No
4.	Has your builder licence ever been subject to conditions, undertakings, limitations or restrictions in Australia or overseas?  

 Yes — you must provide comprehensive details in an attachment to this statement	 No
5.	Have you ever been, or are you currently, the subject of complaints, occupational discipline, demerit activity or rectification orders whilst licensed under the Construction Occupations (Licensing) Act 2004, a corresponding prior Act, or the law of another jurisdiction in Australia or overseas, where those proceedings were not finalised?    

 Yes – you must provide comprehensive details in an attachment to this statement        No

6.	Have you recently, within the last 12 months, provided a reference for another individual applying for a licence in the ACT?
  Yes – Name:                                             					                No 
Verifier Declaration
I, ________________________________________________________________________________________,
 			Insert name, address and occupation of person making the declaration

make the following declaration:
1.	I declare:

a)	that all statements, and the documents/information I have provided to the Construction Occupations Registrar on behalf of the applicant who has made an application to be issued a construction occupations licence are accurate, true and correct.
b)	that building work I have performed under my licence complies with all relevant legislation codes and standards. 
c)	that building work performed by the applicant under my supervision complied with all relevant legislation, codes and standards. 
d)	that my individual licence/registration or the company’s licence was valid at the time of the applicants experience.

2.	I authorise and consent:

a)	to being contacted by Access Canberra for further information relevant to the statements I have made.
b)	to any information I provide being made available to the applicant and other relevant organisations.
c)	to any information I have provided on this form being verified by Access Canberra.

3.	I acknowledge:

a)	that by making false or misleading statements I am committing an offence under Section 337 of the Criminal Code 2002, which is a punishable offence.
b)	the information I provide may result in an individual being offered or refused a licence.
c)	 I must be in a position to adequately verify the applicant’s experience.

4.	I believe that the statements (1 - 3) in this declaration are true and correct

Signature: 							Date: 	       /           /