South Australian Employment Tribunal

Form A51 – Application for Permit (Work Health and Safety)

Form A51

Application for Permit (Work Health and Safety)

Case / Permit Number
(SAET use only)
Approved

About this form

  • This is an application by a union for the issue of a WHS entry permit to a person who is an officer or employee of the union under the Work Health and Safety Act 2012 (SA).
  • A separate application is required for each person.
  • The person who is to hold the WHS entry permit must complete the statutory declaration set out at the end of this form.
  • A copy of the statement/certificate of completion of the prescribed training must be attached to the statutory declaration.
  • Section 125 provides that a WHS entry permit holder must, at all times that he or she is at a workplace under a WHS right of entry, have his or her WHS entry permit and photographic identification available for inspection by any person on request. To facilitate this, the person to be issued the permit may:

(a)attend SAET’s Registry, produce this application, and submit to a photograph being taken by Registry staff; or

(b)attach to the statutory declaration a passport-style photograph, taken within the previous 6 months, with the name of the permit holder on the reverse side. (A guide to acceptable photographs is set out on SAET’s website, “WHS Entry Permits” page.) (do not staple photos to the statutory declaration)

  • Details of WHS permit holders will be published on the SAET website.
  • An original form and statutory declaration is required – do not fax or email.
  • Submitting an incomplete form (including any relevant supporting documents) may result in delays.

Part 1: The Applicant- Details of the union applying for the WHS entry permit

Name of Union
Select the one that applies / ☐ An employee organisation that is registered, or taken to be registered, under the Fair Work (Registered Organisations) Act 2009 (Cth).
☐ An association of employees or independent contractors, or both, registered under the Fair Work Act 1994 (SA).
Name of person making application:
Office or position held:
Address
Telephone / Mobile
Email

Part 2: The Permit Holder- Details of the person who is to hold the WHS entry permit

Full name:
☐ Holds office in the above mentioned union
☐ Is an employee of the above mentioned union.
Office or position held:
☐ Statutory Declaration of the permit holder is attached

Part 3: Signature of Applicant Union

I, the person described in Part 1 of this form, apply for the issue of a WHS entry permit to the person described in Part 2 of this form.

I declare that all of the facts in this application are true and accurate to the best of my knowledge and belief:

[signature of applicant]
Date / /

LODGING YOUR COMPLETED FORM

Name of person lodging
Signature
Date

An original form and statutory declaration are required - do not fax or email.

Please lodge this form, together with any accompanying documents, with the South Australian Employment Tribunal:

Post: PO Box 3636, Rundle Mall, SA, 5000
In person: Level 6, Riverside Centre, North Terrace, Adelaide, 5000

PLEASE RETAIN A COPY OF THIS FORM FOR YOUR OWN RECORDS

STATUTORY DECLARATION

State of South Australia - Oaths Act 1936

I, (full name)
of (address)

do solemnly and sincerely declare that:

  1. I am an officer or employee of (name of union)
  2. I hold/will hold an entry permit under the Fair Work Act 2009 (Cth).
    (delete if not applicable)
  3. I have a right of entry to a workplace under section 140 of the Fair Work Act 1994 (SA).
    (delete if not applicable)
  4. I have satisfactorily completed the training prescribed by the Work Health and Safety Act 2012 (SA) for union officials.
  5. Attached to this Statutory Declaration is a copy of my statement/certificate of completion of the prescribed training.
  6. Attached is a colour photograph of me, taken within the previous 6 months, with my name on the reverse side.
    (delete if not applicable, e.g. permit holder will attend SAET’s Registry, produce this application, and submit to a photograph being taken by Registry staff. N.B. do not staple photo to the statutory declaration.)

And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the provisions of the Oaths Act 1936.

Declared at
in the State of South Australia,
this
day of / 20

Signature of person making this declaration

[to be signed in front of an authorised witness]

Before me,

......

Signature of authorised witness

SAET Registry: 08 8207 0999