Class of Member Applied for (Note 1)

Membership Application Form

Class of member applied for (note 1) :

Fellow Member / Professional Member (Safety) / Professional Member (Health) / Professional Member (General) / Member / Associate Member / Student Member

A. PERSONAL PARTICULARS(note 2)

Surname / First name / 中文姓名
I.D. card or passport no. / Date of birth (dd/mm/yy) / Sex: M/F / Photo
E-mail address (note 3) / Home tel. / Day-time tel.
Residential address
Correspondence address / Mobile phone / pager

B. ACADEMIC QUALIFICATION(note 4)

Attended period
(mm/yy) / Institute/Polytechnic/
University / Course or Major / Certificate/Diploma/
Degree Awarded
From / To

C. OCCUPATIONAL SAFETY AND HEALTH TRAINING (note 4)

Attended period
(mm/yy) / Course organizer / Course / Certificate/Diploma/
Degree Awarded
From / To

D. PROFESSIONAL QUALIFICATIONS(note 4)

Current membership of professional institutions / Year joined

E. PROFESSIONAL REGISTRATION IN LABOUR DEPARTMENT

Status / Date registered (mm/yy) / Registration number
Registered Safety Officer / Yes/No
Registered Safety Auditor / Yes/No

F. CAREER HISTORY IN RELATION TO OSH (IN CHRONOLOGICAL ORDER)

Period (mm/yy) / Organization /
Company / Position held / Functional activities / % of time spent on OSH
From / To

G. APPLICANT’S DECLARATION

I declare that the information given in this application form is true and accurate and that I, if admitted or transferred to membership, will conform to the Memorandum and Articles of the Association.
Signature ______Date ______

H. PROPOSER (who must be a member of the Association)

I have known the Applicant for ____ years and propose him/her to join the Hong Kong Occupational Safety and Health Association to the membership grade applied.
Signature ______Membership No. ______
Name ______Date ______

Please send completed form with photocopy of certificates and application fee (note 5) to: HKOSHA, G.P.O. Box 7100, Central, Hong Kong.

FOR OFFICIAL USE
Date rec’d / Grade admitted
Application fee / Subscription
To Membership Committee / Certificate sent
Approved on / Pocket I/D sent

Note:

1.Please delete as appropriate. This application form is for application to the following grades of members: Fellow Member, Professional Member (Safety), Professional Member (Health), Professional Member (General), Member, Associate Member and Student Member. Information on qualification for these membership grades is available from the web site of the Association:

2.Please inform the Association if your personal particulars are changed.

3.In order to facilitate fast communication and conserve paper, the Association will use E-mail to communicate with its members as far as possible.

4.Photocopy of Certificates to support sections B, C & D must be attached. All photocopies will not be returned to the applicant.

5.Information on application fee is available from the web site of the Association. For Student Member application, no Application Fee is required but must be accompanied by Annual Subscription. Cheques should be addressed to: “The Hong Kong Occupational Safety and Health Association” and crossed. Alternatively, you may pay directly to our bank account (HSBC, no.: 111-078119-001), and fax or mail the transaction record to the Association for confirmation. Please ensure that your name is on such record.

Statement of Purpose for the Collection of Personal Data

by The Hong Kong Occupational Safety and Health Association

(Membership Application)

1.Purpose of Collection

The personal data provided by you by means of this form will be used by the Hong Kong Occupational Safety and Health Association (HKOSHA) for the following purposes:

(a)facilitating processing of your application in this form;

(b)maintenance of a membership record and record of unsuccessful applicants;

(c)facilitating communication between HKOSHA and you;

(d)carrying out research and compilation of statistical data.

2.Transferring of Personal Data

The personal data you provide may be disclosed to relevant parties and authorities (e.g. HK SAR Government Departments, agents of HKOSHA, etc.) for the purposes mentioned in paragraph 1 above.

3.Access to Personal Data

You have a right of access and correction with respect to personal data as provided for in Sections 18 & 22 and Principle of Schedule 1 of the Personal Data (Privacy) Ordinance. Your right of access includes the right to obtain a copy of your personal data provided to HKOSHA.

4.Enquiry

Enquiry concerning the personal data collected, including the making of access and corrections, should be addressed to:

The Honourary Secretary,

The Hong Kong Occupational Safety and Health Association

G.P.O. Box 7100, Central, Hong Kong.

Tel: 2332 9210 Fax: 2770 0542 Email :