Application for a First Class Mine Manager's …

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Page 1 of 3FCMM REV 4Government of Western AustraliaDepartment of mines , Industry Regulation and SafetyApplication for a First Class Mine manager sCertificate of CompetencyABN: 69 410 335 356100 Plain Street, East Perth WA 6004 Telephone: 08 9358 8014 hereby apply for a First Class Mine manager 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 Applicant details (please print)Family name Given names Date of birth / / Email Phone (day) Mobile Postal addressUnit no. Street no. Lot no. Street name PO Box no. Town/suburb State Postcode 2. Examination venue (please tick preferred venue of examination) Perth Kalgoorlie Karratha Collie Have you previously sat this exam? Yes No3. Applicant s declarationI declare the information provided in this Application and the documents provided in support of it, are true and correct.

Page 1 of 3 FCMM RE 4 Government of Western Australia Department of Mines, Industry Regulation and Safety Application for a First Class Mine Manager’s Certificate of Competency

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