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EXTENSION TO REGISTRATION APPLICATION …

EXTENSION TO REGISTRATIONAPPLICATION FORMAPPLICANT BUSINESS1 Trading Title of Business:(as registered with NICEIC Approved Contractor Scheme) REGISTRATION No:Address:Postal Town:County:Postcode:Telephone No:Business Email:Does your business subcontract (outsource) any of its activities? Yes NoIf yes, please detail the activities: Examples: Scaffolding, Design, etcELECTRICAL WORK IN POTENTIALLY EXPLOSIVE ATMOSPHERESPUBLIC LIABILITY INSURANCE2I confirm that the business s public liability insurance policy covers electrical work in potentially explosive atmospheresYes NoPROPOSED QUALIFIED SUPERVISOR(S) (HA)3 Continued overleaf >The following are proposed to be Qualified Supervisors (HA) with particular responsibility for electrical work inpotentially explosive atmospheresCurrently registered with NICEIC as aName.

NICEIC,Warwick House,Houghton Hall Park,Houghton Regis,Dunstable LU5 5ZX HA/APP/10-01-17 T: 0333 015 6625 E:customer.services@niceic.com W: www.niceic.com 4 RANGE AND SCOPE OF EXTENSION TO REGISTRATION FOR HAZARDOUS AREA APPROVAL Explosive Gas/ Vapour (G) Intrinsic Safety (I) Filling Stations

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Transcription of EXTENSION TO REGISTRATION APPLICATION …

1 EXTENSION TO REGISTRATIONAPPLICATION FORMAPPLICANT BUSINESS1 Trading Title of Business:(as registered with NICEIC Approved Contractor Scheme) REGISTRATION No:Address:Postal Town:County:Postcode:Telephone No:Business Email:Does your business subcontract (outsource) any of its activities? Yes NoIf yes, please detail the activities: Examples: Scaffolding, Design, etcELECTRICAL WORK IN POTENTIALLY EXPLOSIVE ATMOSPHERESPUBLIC LIABILITY INSURANCE2I confirm that the business s public liability insurance policy covers electrical work in potentially explosive atmospheresYes NoPROPOSED QUALIFIED SUPERVISOR(S) (HA)3 Continued overleaf >The following are proposed to be Qualified Supervisors (HA) with particular responsibility for electrical work inpotentially explosive atmospheresCurrently registered with NICEIC as aName.

2 (BLOCK CAPITALS)Qualified Supervisor for the business*1**Yes No2**Yes No3**Yes No* Proposed Qualified Supervisors (HA) who are not currently registered with the NICEIC Approved Contractor Scheme as Qualified Supervisor(s) will need to beseparately assessed for compliance with 5(3) of the NICEIC Rules Relating to REGISTRATION before the on-site assessment of electrical work in hazardous areas canproceed - see also the 'Hazardous Area Scheme, Guide to REGISTRATION '** A separate Qualified Supervisor (HA) APPLICATION form is required for each personHA/APP/10-01-17 NICEIC,Warwick House, Houghton Hall Park, Houghton Regis, Dunstable LU5 5ZX T:0333 015 AND SCOPE OF EXTENSION TO REGISTRATION FOR HAZARDOUS AREA APPROVAL4 Explosive Gas/ Vapour (G) Intrinsic Safety (I) filling Stations (F)Combustible Dusts (D) Water/Sewage Treatment (W) Other ELECTRICAL PERSONNEL INVOLVED IN HAZARDOUS AREA WORK, MANAGED FROM THEADDRESS IN SECTION 16 Number of supervisors including proposed Qualified Supervisors (HA):Number of operatives:Number of trainees:Training and experience records available: YesTECHNICAL REFERENCE DOCUMENTS HELD AT THE ADDRESS IN SECTION 17 The latest edition of the following technical reference documents are held:BS EN 60079 Electrical apparatus for explosive gas atmospheres.

3 Part 10-1 - Classification of hazardous areas YesPart 14 - Electrical installations in hazardous areas YesPart 17 - Inspection & maintenance of electrical installations YesBS EN 60079 Electrical apparatus for the use in the presence of combustible dusts:Part 10-2 - Classification of hazardous areas YesPart 14 - Electrical installations in hazardous areas YesPart 17 - Inspection & maintenance of electrical installations YesEEMUA Practitioners Handbook (Publication No 186) Ye sIP/APEA filling station Guide Ye sFor those businesses undertaking work only in filling stations the IP/APEA filling station Guidance is the only reference document required to be LOCATIONS IN WHICH HAZARDOUS AREA WORK IS UNDERTAKEN FROM THEADDRESS IN SECTION 1 (FOR EXAMPLE: filling STATIONS, OIL REFINERIES, FLOUR MILLS)5123456On behalf of the business indicated in Section 1, I confirm that the details given on this form are true and complete.

4 I hereby applyfor an EXTENSION to the scope of REGISTRATION with the NICEIC to cover the range of hazardous area work indicated in Section confirm that the business has sufficient Hazardous Area work available for assessment. I have read and agree to the particularrequirements relating to the EXTENSION of REGISTRATION set out in the NICEIC 'Hazardous Area Scheme, Guide to REGISTRATION '. A separateapplication form for each of the proposed Qualified Supervisors (HA) named in Section 4 is enclosed, together with a cheque for thepreassessment visit fee made payable to Certsure LLP. I understand that this fee is not refundable**.Signed (Registered Principal Duty Holder):Name:Date:**The APPLICATION fee only includes for the Pre-assessment visit to the address indicated in Section 1, not for on-site assessment visits.

5 See the Guide for further details.


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