Application For A Trainee Scaffolding Card - Cisrs

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APPLICATION FOR A TRAINEE SCAFFOLDING CARD
Please read notes overleaf
Affiliated
SECTION A - You, the applicant, must fill in this section. Fill any blank areas and tick the correct boxes.
A1 Your details:
Registration No.
Title
National Insurance No.
ATTACH
Forename
PHOTOGRAPH
HERE WITH
Surname
GLUE
(DO NOT USE
Telephone Number
Home
STAPLES)
Address
Date of Birth
Postcode
D D
MM
Y Y Y Y
E-mail
address:
Type of application being made:
New Card
Duplicate
Renewal
Update
A2 Send my card to:
my home address
The company address in section C
a different address, which is:
Postcode
A3 I confirm to the best of my knowledge the information above is correct and I agree to comply with the CISRS criteria relating to
trainee cards as laid out in the CISRS Scheme Booklet. I understand and agree that the information on this form will be used by
CITB and CISRS for the purposes of administering the CISRS Scheme, this may include passing on information to Employers or
Training Providers and for this purpose, your data and image (photo) may be entered onto a secure database accessible via a
website.
Please note that all application fees are non-refundable. If your application is incomplete you will be given 180 days to
resolve any issues. Any applications returned after 180 days will be subject to an additional £26.50 non-refundable
application fee.
We may contact you by mail, telephone or e-mail to let you know about other goods or services or promotions which
may be of interest to you. Please tick this box if you wish to receive such information from us.
Date:
Applicant Signature
D D
MM
Y Y Y Y
Please send VAT receipt
SECTION B -
Scaffolding Courses completed - you, the applicant, employer sponsor or Training Provider may complete this section
Please
Course
Please
Course
Training Centre/Employer Sponsor Name
Training Centre Name
tick
tick
Type
Type
CISRS Operative Training
Part 1
Scheme (COTS)
Part 2
Apprentice Induction
Details of Systems Type/Brand to be endorsed:
Copies of training certificates must be attached, failure to do so will result in your form being returned.
SECTION C - Employer Declaration - a current employer sponsor or Training Provider must complete this section
By completing and signing the declaration below, I certify that:
• The details on this form are correct to the best of my knowledge and that the photograph is a true likeness of the applicant.
• I have read the information on Health and Safety and confirm that the applicant has either passed the CITB Health, safety and
environment test within the last 2 years or meets the exemption requirements (you must attach a copy of certificate).
• I have read and understood the scheme rules relating to trainee cards (overleaf) and agree to adhere to them.
PLEASE ENSURE THIS BOX IS FULLY COMPLETED (The applicant cannot complete this section)
Employer Sponsor/Training Provider name:
Signature:
Address:
Print name:
Telephone number:
Postcode
Date
Please see reverse of form for further information on your application.
Form number: CISRS01/08/13

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