Application for Construction Occupation Licence Individual 
Gas Appliance Worker
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 a gas appliance worker licence to provide gas appliance services 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 by Access Canberra then Access Canberra cannot process your application. The personal information you provide may be disclosed to the other areas of ACT Government 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 
http://www.cmd.act.gov.au/legal/privacy.

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 AF2016‐55 approved by Ben Green, Deputy Construction Occupations Registrar on 27 June 2016 under
section 128 of the Construction Occupations (Licensing) Act 2004 and revokes AF2015-119.	

Section B — Existing licence
Have you previously or do you currently hold an ACT construction occupation licence?

 Yes — Licence number				 expiry date				

 No — proceed to Section C – Occupation class and functions.
Section C — Occupation class and functions
A gas appliance worker is an entity that is licensed to provide a gas appliance service. A gas appliance service is the undertaking or supervising of type A gas appliance work or type B gas appliance work. See the Gas Safety Act 2000, section 6B, for the definition of type A gas appliance work. See the Gas Safety Act 2000, section 6C, for the definition of type B gas appliance work.

What class of licence are you applying for?

 Unrestricted Type A –	licence authorises type A gas appliance work without supervision

 Restricted Type A –	licence authorises type A gas appliance work under the supervision of a licensee with an unrestricted type A licence

 Unrestricted Type B –	licence authorises type B gas appliance work without supervision

 Restricted Type B – Level 2 –	licence authorises, without supervision, type B gas appliance work on an atmospheric type gas appliance that consumes less than 2000MJ/h; or a forced draft burner system that consumes less than 500MJ/h; and licence authorises any other type B gas appliance work under the supervision of an Unrestricted Type B.

 Restricted Type B – Level 1 –	 licence authorises type B gas appliance work under the supervision of a licensee with an unrestricted type B licence or a restricted type B–level 2 licence that authorises the licensee to perform the work to be completed unsupervised

Section D — Evidence of qualifications/eligibility — Unrestricted Type A 
Complete this section if you are applying for an Unrestricted Type A Gas Appliance Worker licence.

Method One

Qualification:	Have successfully completed a qualification in Service Type A Gas Appliances with a course code of CPCPGS4022A, CPCPGS4012A or CPCPGS4002A. The certificate must have been issued within five (5) years prior to making the application:

 Yes — attach a certified copy of the unit(s) of competency to this application.

 No — please note that you may not be eligible for a licence.

Requirement:	hold a licence issued under the Construction Occupations (Licensing) Act 2004 in one of the following occupation classes:
 	
 	Advanced Gasfitter or 
 	General Gasfitter.

 Yes — attach a photocopy of the licence. 

 No — please note that you may not be eligible for a licence.

Method Two

Qualification:	Have successfully completed a qualification in Service Type A Gas Appliances with a course code of CPCPGS4022A, CPCPGS4012A or CPCPGS4002A. The certificate must have been issued within five (5) years prior to making the application:

 Yes — attach a certified copy of the unit(s) of competency to this application.

 No — please note that you may not be eligible for a licence.

Qualification:	have successfully completed the following unit of competency issued within (5) years prior to making the application:

 	CPCPCM2041A – Work effectively in the plumbing and services sector
	CPCPCM2043A – Carry out WHS requirements
	HLTAID002 – Provide basic emergency life support
	CPCPGS3051A – Purging consumer piping
	CPCPGS3052A – Maintain Type A gas appliances
	CPCPGS3053A – Disconnect and reconnect Type A appliances
	CPCPGS3054A – Calculate and install natural ventilation for Type A appliances
	CPCPCM4011A - Carry out work based risk control processes 

 Yes — attach a certified copy of the unit(s) of competency to this application.

 No — please note that you may not be eligible for a licence.

Experience:	Demonstrate not less than 2 years experience undertaken whilst the applicant was a Restricted Type A Gas Appliance Worker, or interstate equivalent, on gas appliances relevant to a an Unrestricted Type A Gas Appliance licence. 

 Yes — please attach a resume detailing the two years experience on servicing Type A Gas appliances. Please advise the Unrestricted Type A Gas Appliance licensee who supervised you undertaking the work. 

 No — please note that you may not be eligible for a licence.
Supervisor (Licensee) Name				Licence Number	 			
	
Section D — Evidence of qualifications/eligibility — Restricted Type A 
Complete this section if you are applying for a Restricted Type A licence.  

Requirement:	The applicant satisfies the registrar that the applicant has enrolled into the course Service Type A Gas Appliances a unit code of CPCPGS4022A.

 Yes — please attach a copy of enrolment papers or a letter from a registered training organisation   indicating that there is an enrolment. 

 No — please note that you may not be eligible for a licence.

Requirement:	The applicant has a letter from the applicant’s employer/supervisor, whomever holds an Unrestricted Type A Gas Appliance licence, advising that they will be responsible for supervising the applicant should they be successful in gaining the Restricted Type A Gas Appliance Worker licence. 

 Yes — please provide details of the licensee below and attach a copy of the reference from the licensed Unrestricted Type A Gas Appliance Worker.

 No — please note that you may not be eligible for a licence.
Supervisor (Licensee) Name				Licence Number	 			

Section D — Evidence of qualifications/eligibility — Unrestricted Type B
Complete this section only if you are applying for an Unrestricted Type B Gas Appliance Worker licence.

Qualification:	Have successfully completed a qualification in Design Industrial Gas Systems with a course code of CPCPPS5001B or CPCPPS5001A. The certificate must have been issued within five (5) years prior to making the application.

 Yes — attach a certified copy of the certificate to this application.

 No — please note that you may not be eligible for a licence.

Qualification:	Have successfully completed a qualification in Install Type B Gas Appliance Flue with a course code of CPCPGS3050A, CPCPGS3020A or CPCPGS3010A. The certificate must have been issued within five (5) years prior to making the application.

 Yes — attach a certified copy of the certificate to this application.

 No — please note that any licence issued may restrict you from performing this type of work.

Requirement:	The applicant has, or had previously held within twelve months prior to application, a Restricted Type B – Level 2 Gas Appliance Worker licence or interstate equivalent.

 Yes — please provide details of the licence below.

 No — please note that you may not be eligible for a licence.
Licence Number	 			          State issued in					

Experience:	Demonstrate not less than 2 years experience undertaken whilst the applicant was licensed as a Restricted Type B – Level 2 Gas Appliance Worker  on gas appliances relevant to a an Unrestricted Type B Gas Appliance licence. 

 Yes — please attach a resume detailing the two years relevant experience on Type B Gas appliances. Please advise the Unrestricted Type B Gas Appliance licensee who supervised you undertaking the work. 

 No — please note that you may not be eligible for a licence.
Supervisor (Licensee) Name				Licence Number	 			
Section D — Evidence of qualifications/eligibility
                        Restricted Type B – Level 2 
Complete this section if you are applying for an Restricted Type B – Level 2 Gas Appliance Worker licence.

Qualification:	Have successfully completed a qualification in Install, Commission and Service Type B Appliances with a course code of CPCPGS4023B, CPCPGS4023A or CPCPGS4003A. The certificate must have been issued within five (5) years prior to making the application.

 Yes — attach a certified copy of the certificate to this application.

 No — please note that you may not be eligible for a licence.

Qualification:	Have successfully completed a qualification in Install Type B Gas Appliance Flue with a course code of CPCPGS3050A, CPCPGS3020A or CPCPGS3010A. The certificate must have been issued within five (5) years prior to making the application.

 Yes — attach a certified copy of the certificate to this application.

 No — please note that any licence issued may restrict you from performing this type of work.

Experience:	Demonstrate not less than 2 years experience undertaken whilst the applicant was licensed as a Restricted Type B – Level 1 Gas Appliance Worker  on gas appliances relevant to a an Unrestricted Type B Gas Appliance or a Restricted Type B – Level 2 licence. 

 Yes — please attach a resume detailing the two years relevant experience on Type B Gas appliances. Please advise the Unrestricted Type B Gas Appliance or Restricted Type B – Level 2 licensee who supervised you undertaking the work. 

 No — please note that you may not be eligible for a licence.
Supervisor (Licensee) Name				Licence Number	 			

Section D — Evidence of qualifications/eligibility 
                        Restricted Type B – Level 1
Complete this section if you are applying for a Restricted Type B – Level 1 licence.  

Requirement:	The applicant satisfies the registrar that the applicant has enrolled into the course Install, Commission and Service Type B Appliances with a unit code of CPCPGS4023B and Install Type B Gas Appliance Flues with a unit code of CPCPGS3050A.

 Yes — please attach a copy of enrolment papers or a letter from a registered training organisation   indicating that there is an enrolment. 

 No — please note that you may not be eligible for a licence.

Requirement:	The applicant has a letter from the applicant’s employer/supervisor, whomever holds an Unrestricted Type B or Restricted Type B – Level  2 Gas Appliance licence, advising that they will be responsible for supervising the applicant should they be successful in gaining the Restricted Type B – Level 1 Gas Appliance Worker licence. 

 Yes — please provide details of the licensee below and attach a copy of the reference from the licensed Unrestricted Type A Gas Appliance Worker.

 No — please note that you may not be eligible for a licence.
Supervisor (Licensee) Name				Licence Number	 			
Section E — Evidence of Financial Resources 
                      (not required for Restricted Type A or Restricted Type B- Level 2)
Evidence of financial resources is required to help demonstrate your ability to fulfil contractual obligations when providing construction services.  Failure to provide information below may result in your licence being refused. 

1.	Do you have access to financial resources adequate to complete works performed under the licence applied for?  

 Yes – please skip the next question.				

 No – complete next question.

2.	If ‘No’ to the above, do you wish to only operate as an employee under the licence applied for?

 Yes – I understand a condition may be imposed on the licence if issued.  

 No— if you do not wish to have a licence restricted to employee only, then you must ensure you have financial resources as requested above or you may be ineligible for a licence).

3.	Are you currently, or previously have been, deemed bankrupt or personally insolvent? 

 Yes – please attach details and official documentation of bankruptcy/insolvency.    		

 No.

4.	I understand that it is a requirement under law that should my licence be issued, I must notify the Construction Occupations Registrar should I become bankrupt or personally insolvent?  

 I have read and understand the above statement.

Section F — Licence History Declarations
1.	Have you previously held a gas appliance worker 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 gas appliance worker, in Australia or overseas, currently suspended or cancelled?  

 Yes — you must attach details     							 No 

3.	Have you previously had a gas appliance worker 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 gas appliance worker licence is cancelled, refused or suspended in Australia or overseas.  

 I have read and understand the above statement. 

5.	Has your gas appliance worker 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 gasfitting services that are 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 gasfitting services I may perform under my gasfitter licence must comply with all relevant legislation, codes and standards. 

 I have read and understand the above statement.

Please note: Gas appliance 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 G — 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 the ACT Government 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 an electrician or otherwise regarding matters relevant to this application.

b)	to receive 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 ACT Government 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 occupations 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 H — Payment Details
Upon lodgement of your application you will be required to pay an application assessment fee.  This fee is non‑refundable. You will be provided with a notice of decision in relation to your application. If your application is approved a licence term fee will be payable prior to the issue of your licence.  
View the Access Canberra Website for licence application fee and charges.

Section I — 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 8096

Email: cwpl@act.gov.au