Legal Advice Request Form

Contaminated sites auditor scheme

Contaminated Sites Regulations 2006 regulation 44(2)

Form C:Application for accreditation renewal

This form is forRenewal. Please complete and attach Form D.
Part 1 Applicant details
Full name
Contact address
Postal address
(if different from above)
Telephone
Mobile
Fax
Email
Current employer
(company name)
Part 2Required supporting information/documentation
This application form will not be processed without these being attached/completed.
For what period of accreditation are you seeking renewal? (maximum of five years) / years
Yes / No
Are you familiar with the statutory requirements of the accredited auditors scheme in WA pursuant to the Contaminated Sites Act 2003 and Contaminated Sites Regulations 2006? / ☐ / ☐ /
Have you provided details of your expert support team? (refer Form D) / ☐ / ☐ /
Have you provided details of contaminated sites audits undertaken or in progress since you were accredited or your accreditation was last renewed? / ☐ / ☐ /
Have you provided details of your continuing professional development (including training courses completed) since your accreditation or most recent renewal? / ☐ / ☐ /
Current accreditation date / Current accreditation expiry date
Are details of your current professional indemnity insurance coverage attached? / ☐ / ☐ /
Part 3 Payment
Payment in advance is required—250 fee units (currently $3,750) per year for the period of accreditation being sought.
Have you attached the correct payment? / ☐ / ☐ /
Part 4Declaration and signature
Under the Contaminated Sites Act 2003, s 71, it is an offence to obtain or attempt to obtain accreditation as an auditor by—

• providing information which you know is false or misleading in a material particular;
  
• providing information that is false or misleading in a material particular with reckless disregard as to whether or not the information is false or misleading in material particular; or
  
• failing to disclose information that you know is materially relevant.

I declare that the information in this form, and provided with this form, is true and is not misleading in any material particular and that I have disclosed all information that I know is materially relevant to this application.
______Date
(Applicant’s signature)
______
(Full name in block capitals)

Form C: Application for accreditation renewal (July2017)1