Application for Backflow Prevention Testing Endorsement
Construction Occupations (Licensing) Act 2004, s128 and s17	

This approved form is to be used for individuals applying under the Construction Occupations (Licensing) Act 2004 to the Construction Occupations Registrar for an endorsement for backflow prevention device test work in the ACT.  This application will not be considered unless it is complete and all supporting documentation provided.

All supporting documentation must:
•	be originals or certified true copies of original documents where relevant; and
•	be in English. If original documents are not in English, you must provide a certified copy of the original document and an official translation of the document.
Privacy Notice 
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 legislation 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 CMTEDD website, under the "Privacy" menu. 

Section A — Personal Details
Title 		 Surname 									 

Given Names							Date of Birth	    /	  /	

Business Address											 

Suburb 					State				Postcode 		

Residential Address										 

Suburb 					State				Postcode 		
	
Postal Address 											           

Suburb 					State				Postcode 		

Phone Number (Business Hours) 				Fax 					

Mobile Number* 				Email*							

*Please note that under S170 of the Construction (Occupations) Licensing Act 2004 it is a requirement to provide a valid mobile telephone number and email address. 

I understand that it is a requirement under law that should my licence be issued I must notify the Construction Occupations Registrar of any changes to my details within two weeks of the change?  

 I understand

Approved form AF2016‐15 approved by Ben Green, Deputy Construction Occupations Registrar on 19 April 2016 under
section 128 of the Construction Occupations (Licensing) Act 2004.	

Section B — Existing Plumber Licence
Have you previously held or do you currently hold an ACT Plumber licence?

 Yes – licence number				Expiry date					 

 No –please note you may not be eligible for an endorsement.
Section C – Endorsement
The Construction Occupations Registrar may endorse a licence holder (in addition to what the scope of licence already authorises) if satisfied that licensee can safely and competently perform the additional works.

Definition	The Construction Occupations (Licensing) Regulation 2004 defines Backflow prevention device test work as work in accordance with Australian Standard 2845.3, Water Supply-Backflow prevention devices-Field testing and maintenance, to test, or supervise the testing or, a backflow prevention device that forms part of a water service, hot-water system, irrigation system or fire sprinkler system: or the production of a report about a test in relation to one of the above services.

Do you wish to be endorsed to perform backflow prevention device test work?

 Yes – Please attach certified evidence of completion of the Backflow prevention course      

 No – You are not required to submit an application if you are not intending to perform backflow prevention device test work
*Please note that additional information may be required for endorsements at the discretion of the Construction Occupations Registrar. You will be notified if additional information is required. 

The Construction Occupations Registrar will take into consideration any demerit activity or disciplinary action recorded against the applicant under the Construction Occupations (Licensing) Act 2004.
Section D — Licence History Declarations
1.	Have you previously held a Plumber licence elsewhere in Australia or overseas? 

 Yes —provide details below of most recent licence/s (attach an additional page if required)    No

	State/Territory/Country ___________________________Expiry date:   ______/______/______  

2.	Is your licence as a Plumber, in Australia or overseas, currently suspended or cancelled?  

 Yes — you must attach details     							 No 

3.	Have you previously had a Plumber licence cancelled, refused or suspended in Australia or overseas?      

 Yes — you must provide comprehensive details in an attachment to this application	  No

4.	I understand that I must notify the Construction Occupations Registrar if my Plumber licence is cancelled, refused or suspended in Australia or overseas. 

 I have read and understand the above statement. 

5.	Has your Plumber 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 application	 No

6.	Are you disqualified under the Construction Occupations (Licensing) Act 2004, or a corresponding prior Act, from applying for licence, or being licensed, in a construction occupation? 

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

7.	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 application	 No

8.	Have you been convicted or found guilty of a criminal offence* that involves fraud, dishonesty or violence and is punishable by imprisonment of 1 year or more? 

 Yes — you must provide comprehensive details in an attachment to this application 	 No
   and a recent criminal history check  (issued in the last three months).				
*Please note: Spent convictions under the Spent Convictions Act 2000 do not need to be included in this declaration

9.	I understand that it is a requirement under law that should my licence be issued I must notify the Construction Occupations Registrar if I am convicted of such an offence in the future.  

 I have read and understand the above statement.

10.	I understand that it is a requirement under law that should my licence be issued I must not perform any licensable plumbing service that is outside the scope of what the licence authorises.  

 I have read and understand the above statement. 

11.	I understand that it is a requirement under law that should my licence be issued  I must give evidence to clients of the insurance I hold as a licensed individual in relation to any relevant licensable construction service I intend to undertake prior to providing the services.

  I have read and understand the above statement.

12.	I understand that it is a requirement under law that should my licence be issued I must only advertise licensable construction services with my full name (as it appears on the licence) and my individual licence number.*  

 I have read and understand the above statement.

*Please note: It is an offence to advertise licensable construction services as an individual without including the above.

13.	I understand that it is a requirement under law that should I be granted a licence, all licensable plumbing services I may perform under my Plumbers licence must comply with all relevant legislation, codes and standards. 

 I have read and understand the above statement.

*Please note: Plumbing work may be audited by the Construction Occupations Registrar in the ACT for compliance against the relevant laws. Individual licence holders identified performing non-compliant services may be subject to occupational discipline or other licensing action.
Section H — Consent and Application Declaration
I, ________________________________________________________________________________________,
 			Insert name, address and occupation of person making the declaration

make the following declaration:

1.	I declare:

a)	that I make this application to the Construction Occupations Registrar for a construction occupations licence and that all statements, and the documents/information provided in support of the application, are accurate, true and correct.

2.	 I authorise and consent:

a)	to the Construction Occupations Registrar and Environment and Planning Directorate to make enquiries of, and exchange information with, the relevant regulatory authorities of any Australian State or Territory, or other country, regarding my construction occupation licence and practice as a plumber or otherwise regarding matters relevant to this application.

b)	to receiving information from the Construction Occupations Registrar relevant to my construction occupation licence or the construction industry electronically.

3.	I acknowledge:

a)	that the Construction Occupations Registrar and EPD may validate documents provided in support of this application or wish to confirm my identity.

b)	that failure to complete all relevant sections of this application and enclose all supporting documentation may result in this application not being accepted or additional fees being applied as per the statutory instrument authorising fees to be taken under the Construction Occupations (Licensing) Act 2004

c)	that the Construction Occupations Registrar has the legal right to refuse my application if not satisfied that I am eligible to hold a licence or impose a condition on my  licence if it is deemed necessary or desirable to protect the public.

4.	Should I be issued with a construction occupation licence I undertake:

a)	to comply with the Construction Occupations (Licensing) Act 2004 (and it’s operational Acts) and the codes, standards and guidelines relevant to my construction occupation licence when providing, or offering to provide, a relevant construction service.

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

Signature of Applicant 							Date 			  
Section I — Payment Details
Upon lodgement of your application you will be required to pay an application assessment fee.  This fee is $60.00 and is non-refundable.

Should your application be approved, a new card reflecting the endorsement will be posted to your nominated postal address. You will be provided with a notice of decision in relation to your application should your application be unsuccessful. 
Section J — Lodgement and Contact Information
Access Canberra Environment Planning and Land Shopfront
GPO Box 1908, Canberra City 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