Application For A Winding Engine Driver'S Certificate Of Competency - Western Australia Department Of Mines And Petroleum
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Application for a Winding Engine Driver’s
Certificate of Competency
ABN: 69 410 335 356
I hereby apply for a Winding Engine Driver’s Certificate of Competency under the Mines Safety and Inspection Act 1994 and Mines
Safety and Inspection Regulations 1995, and submit the following documentation and information.
1. Applicant details
(please print)
Family name
Given names
Date of birth
/
/
Email
Phone (day)
Facsimile
Mobile
Postal address
Unit no.
Street no.
Lot no.
Street name
PO Box no.
Town/suburb
State
Postcode
2. Examination details
I am making an application for a Winding Engine Driver’s Certificate of Competency
Class I
Class II
Have you previously sat this exam?
Yes
No
Please contact the Executive Offiver of the Board of Examiners to arrange an examination time.
3. Statutory declaration
I (name in full)
of (address)
declare that the foregoing particulars are true and correct in every detail and I make this solemn declaration under the Oaths, Affidavits and
Statutory Declarations Act 2005. (For information on who can witness statutory declarations, refer to the Department of the Attorney General’s
website at )
Declared at
in the state or territory of
Date
/
/
Signature of declarant
Before me (signature of witness)
Name of witness
Address of witness
Postcode
Title or qualification of witness
WED REV 1
Telephone: 08 9358 8014
100 Plain Street, East Perth WA 6004
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