Application Form JIB-PMES CSCS Card

Transcription

1 HOW TO APPLY Enter your name, address and other personal details on this page. Provide a passport-size colour photograph of yourself.write your name and National Insurance number clearly on the back of the photograph. Attach the photograph to this form in the space provided. Provide details of the health and safety awareness training/testing you have received in Section 2 and at the appropriate section of the application form. All applicants must complete Sections 1, 2, 3 and 4. Applicants are also required to complete the appropriate Section for the JIB-PMES CSCS Card for which they are applying. The appropriate Sections are detailed in the table opposite. Applicants must tick the appropriate box for the JIB-PMES CSCS Card they wish to apply for and ensure they complete the appropriate Section. REMEMBER TO ENSURE THAT YOU ARE ELIGIBLE FOR THE CARD YOU ARE APPLYING FOR. IF YOU ARE NOT ELIGIBLE FOR THE CARD, YOUR APPLICATION WILL BE RETURNED WITHOUT REGISTRATION IN ANY OTHER CATEGORY. Section 1 Application Form JIB-PMES CSCS Card Upon satisfactory completion of this form and appropriate payment, you will receive your JIB-PMES CSCS Card, in accordance with the conditions of JIB-PMES CSCS Card Scheme. See the scheme booklet for further details or visit the website: IMPORTANT NOTE: Please send good quality photocopies of NVQ/SVQ completion certificates or City & Guilds Craft/Advanced Craft completion certificates for verification. These must be the genuine copies, the JIB-PMES undertakes random checks for authenticity. If you have any queries about this form or how to complete it, please refer to the scheme booklet or call for assistance. Card Applied For Card Colour Complete Plumber Blue Section 5 Plumber Gold Section 6 Heating Fitter Blue Section 7 Heating Fitter Gold Section 8 Mechanical Pipe Fitter Blue Section 9 Mechanical Pipe Fitter Gold Section 10 Plumbing Related Occupations White Section 11a Gas Installer/Fitter/Engineer Plumbing Related Occupations White Section 11b Plumbing Employee Green Section 12 Plumbing Apprentice/Trainee Red Section 13 Supervisor Gold Section 14a Manager Platinum Section 14b Site Visitor Yellow Section 15 Your Details Surname First Name Please attach your photograph here House Number / Name Town Street County National Insurance Number Date of Birth D D M M Y Y Y Y / / Home Telephone Number Mobile Telephone Number (optional) (Persons applying for gold cards must be at least 21 years old) (Persons applying for blue cards must be at least 20 years old) Address Your Sex Date you started in the industry How would you describe your Ethnic Origin? D D M M Y Y Y Y White Asian (Indian/Pakistani/Bangladeshi) Male Female Black (African descent) Asian (Chinese) Black (Caribbean descent) Other (e.g. mixed race) If you are a member of Amicus the union and would like to apply for free JIB-PMES CSCS registration please enter your membership number here If you are employed by a JIB participant company, and wish to apply for free registration please provide the company name

2 Section 2 Health and Safety Training SECTION 2: Health and Safety Training 1. NVQ/SVQ Exemption If you have obtained relevant Level 2 or 3 National or Scottish Vocational Qualification is (NVQ/SVQ) within the past two years, tick this box (To ensure the NVQ/SVQ exemption is accepted, you must attach a copy of your NVQ/SVQ completion certificate to this application). Please Note: Level 1 or 6129 VRQ certificates are not acceptable 2. Recognised JIB-PMES/CITB Health and Safety Test Full title of test taken Organisation providing course Date attended D D M M Y Y Y Y Please attach your Test Certificate or Pass Letter / / 3. Other Safety Course (Important note this must be a course that is recognized by the JIB-PMES (i.e.nebosh construction certificate, IOSH (construction related) or CCNSG safety passport. ) Further details regarding suitable courses are included in the scheme booklet). Title of course Organisation providing course Date attended D D M M Y Y Y Y Please attach your completion certificate / / Section 3 Fees SECTION 3: Fees Please ensure that the appropriate fee is included with the application.the table below shows the fees that are charged for individual cards, please tick the appropriate box to confirm that the fee has been included. Please make cheques payable to JIB-PMES.There is no fee to pay if the applicant is a member of Amicus the union or the company is a JIB-PMES Participant. Fees at the time of publication (September 2006) are: Plumber, Heating Fitter & Mechanical Pipe Fitter Blue card Plumber, Heating Fitter & Mechanical Pipe Fitter Gold card Plumbing Related Occupation - Gas card Plumbing Related Occupation card Plumbing Employee card Apprentice/Trainee card Supervisors card Managers card Regular Visitor card Update and Replacement card Renewals (all categories) JIB-PMES Registered company FREE Member of Amicus the union FREE

3 Check List Once you have completed all the other relevant sections of the application form please double check that you have: Completed the appropriate sections for the card you are applying for Provided evidence of qualifications/testimony s required to support card application Provided satisfactory evidence that you meet JIB-PMES CSCS Card Health and Safety requirements Included the appropriate fee for the card being appiled for Included a recent photograph (with your name and National Insurance Number written on the back) If you are satisfied that you have completed all the steps outlined above, sign the declaration at Section 4 and return your form to the JIB-PMES. Please again note, that failure to comply with any of the requirements outlined in the check list will result in the immediate return of the application form. Section 4 Declaration SECTION 4: Applicants Declaration I certify that the details on this application form are correct and completed to the best of my knowledge I acknowledge that the personal information given here will be used for the purpose of processing my application for a card. I also understand that, once I have been issued with my card, information from this application form may be held on a database in accordance with the Data Protection Act Signed Date D D M M Y Y Y Y / / Important Note: If all documentation is not enclosed with the application form, the whole application will be returned.

4 All documentation should be returned to: JIB-PMES Lovell House, Sandpiper Court, Phoenix Business Park, Eaton Socon, St. Neots, Cambridgeshire PE19 8EP Please note: The website contains all the latest amendments to the JIB-PMES Card Registration Scheme rules.

5 Section 5 Plumber Blue Card Name National Insurance Number Plumber Blue Card To apply for this card applicants must be a minimum of 20 years old. Minimium qualification - NVQ/SVQ Level 2 Plumbing or City & Guilds Craft Certificate - Important note: City & Guilds 6089 NVQ is required not the City & Guilds 6129 Technical Certificate. Plumbing Please tick against qualification obtained Health & Safety Please tick against safety qualifications obtained NVQ/SVQ Level 2 SCOTVEC Modules NVQ/SVQ Exemption JIB-PMES/CITB Health & Safety test City & Guilds Craft NARIC Equivalence Report Other Approved Safety Course Please ensure you send copies of all your completion certificates with this application Please ensure you send copies of your test/course certificates with this application I confirm that I have worked in the plumbing industry since Y Y Y Y Confirmation of the details I have included on this application form can be obtained from: (If you are self employed the contact details below must be from a registered company, JIB-PMES approved agency* or public sector organisation (this should not be from a domestic client)) Contact person (must be a senior member of staff/director) Name of Employer/Company Address Address Telephone Number Please note that checks will be made with the contact person to ensure that details included on this form are accurate and that you are employed in the PMES sector. * For details of JIB-PMES approved labour agencies please phone or visit the website

6 Section 6 Plumber Gold Card Name National Insurance Number Plumber Gold Card To apply for this card applicants must be a minimum of 21 years old. Minimium qualification - NVQ/SVQ Level 3 Plumbing or City & Guilds Advanced Craft Certificate Plumbing Please tick against qualification obtained Health & Safety Please tick against safety qualifications obtained NVQ/SVQ Level 2 NVQ/SVQ Level 3 City & Guilds Craft City & Guilds Advanced Craft SCOTVEC Modules NVQ/SVQ Exemption Other Approved Safety Course JIB-PMES/CITB Health & Safety test Please ensure you send copies of all your completion certificates with this application Please ensure you send copies of your test/course certificates with this application I confirm that I have worked in the plumbing industry since Y Y Y Y Confirmation of the details I have included on this application form can be obtained from: (If you are self employed the contact details below must be from a registered company, JIB-PMES approved agency* or public sector organisation (this should not be from a domestic client)) Contact person (must be a senior member of staff/director) Name of Employer/Company Address Address Telephone Number Please note that checks will be made with the contact person to ensure that details included on this form are accurate and that you are employed in the PMES sector. * For details of JIB-PMES approved labour agencies please phone or visit the website

7 Section 7 Heating Fitter Blue Card Name National Insurance Number Heating Fitter Blue Card To apply for this card applicants must be a minimum of 20 years old. Minimium qualification - NVQ/SVQ Level 2 or City & Guilds Craft Certificate Please tick against qualification obtained Health & Safety Please tick against safety qualifications obtained NVQ/SVQ Level 2 NARIC Equivalence Report NVQ/SVQ Exemption JIB-PMES/CITB Health & Safety test City & Guilds Craft SCOTVEC Modules Other Approved Safety Course Please ensure you send copies of all your completion certificates with this application Please ensure you send copies of your test/course certificates with this application I confirm that I have worked in the plumbing industry since Y Y Y Y Confirmation of the details I have included on this application form can be obtained from: (If you are self employed the contact details below must be from a registered company, JIB-PMES approved agency* or public sector organisation (this should not be from a domestic client)) Contact person (must be a senior member of staff/director) Name of Employer/Company Address Address Telephone Number Please note that checks will be made with the contact person to ensure that details included on this form are accurate and that you are employed in the PMES sector. * For details of JIB-PMES approved labour agencies please phone or visit the website

8 Section 8 Heating Fitter Gold Card Name National Insurance Number Heating Fitter Fitter Gold Card To apply for this card applicants must be a minimum of 21 years old. Minimium qualification - NVQ/SVQ Level 3 or City & Guilds Advanced Craft Certificate Please tick against qualification obtained Health & Safety Please tick against safety qualifications obtained NVQ/SVQ Level 2 NVQ/SVQ Level 3 City & Guilds Craft City & Guilds Advanced Craft SCOTVEC Modules NVQ/SVQ Exemption Other Approved Safety Course JIB-PMES/CITB Health & Safety test Please ensure you send copies of all your completion certificates with this application Please ensure you send copies of your test/course certificates with this application I confirm that I have worked in the plumbing industry since Y Y Y Y Confirmation of the details I have included on this application form can be obtained from: (If you are self employed the contact details below must be from a registered company, JIB-PMES approved agency* or public sector organisation (this should not be from a domestic client)) Contact person (must be a senior member of staff/director) Name of Employer/Company Address Address Telephone Number Please note that checks will be made with the contact person to ensure that details included on this form are accurate and that you are employed in the PMES sector. * For details of JIB-PMES approved labour agencies please phone or visit the website The JIB-PMES/CSCS Plumbing Registration Sche

9 Section 9 Mechanical Pipe Fitter Blue Card Name National Insurance Number Mechanical Pipe Fitter Blue Card To apply for this card applicants must be a minimum of 20 years old. Minimium qualification - NVQ/SVQ Level 2 or City & Guilds Craft Certificate Please tick against qualification obtained Health & Safety Please tick against safety qualifications obtained NVQ/SVQ Level 2 NARIC Equivalence Report NVQ/SVQ Exemption JIB-PMES/CITB Health & Safety test City & Guilds Craft SCOTVEC Modules Other Approved Safety Course Please ensure you send copies of all your completion certificates with this application Please ensure you send copies of your test/course certificates with this application I confirm that I have worked in the plumbing industry since Y Y Y Y Confirmation of the details I have included on this application form can be obtained from: (If you are self employed the contact details below must be from a registered company, JIB-PMES approved agency* or public sector organisation (this should not be from a domestic client)) Contact person (must be a senior member of staff/director) Name of Employer/Company Address Address Telephone Number Please note that checks will be made with the contact person to ensure that details included on this form are accurate and that you are employed in the PMES sector. * For details of JIB-PMES approved labour agencies please phone or visit the website

10 Section 10 Mechanical Pipe Fitter Gold Card Name National Insurance Number Mechanical Pipe Fitter Gold Card To apply for this card applicants must be a minimum of 21 years old. Minimium qualification - NVQ/SVQ Level 3 or City & Guilds Advanced Craft Certificate Please tick against qualification obtained Health & Safety Please tick against safety qualifications obtained NVQ/SVQ Level 2 NVQ/SVQ Level 3 City & Guilds Craft City & Guilds Advanced Craft SCOTVEC Modules NVQ/SVQ Exemption Other Approved Safety Course JIB-PMES/CITB Health & Safety test Please ensure you send copies of all your completion certificates with this application Please ensure you send copies of your test/course certificates with this application I confirm that I have worked in the plumbing industry since Y Y Y Y Confirmation of the details included on this application form can be obtained from: (If you are self employed the contact details below must be from a registered company, JIB-PMES approved agency* or public sector organisation (this should not be from a domestic client)) Contact person (must be a senior member of staff/director) Name of Employer/Company Address Address Telephone Number Please note that checks will be made with the contact person to ensure that details included on this form are accurate and that you are employed in the PMES sector. * For details of JIB-PMES approved labour agencies please phone or visit the website

11 Section 11a Plumbing Related Occupations - Gas Installer/Fitter/Engineer White Card Name National Insurance Number SECTION 11a: Plumbing Related Occupations Gas Installer/Fitter/Engineer White Card Please state your occupation below: CORGI operative ID number Please note: Applications will be returned if a valid CORGI operative ID number is not provided. Health & Safety Please tick against safety qualifications obtained: NVQ/SVQ Exemption Other Approved Safety Course JIB-PMES/CITB Health & Safety test Please ensure you send copies of your test/course certificates with this application. CURRENT EMPLOYMENT STATUS Please tick one of the following: Self employed* Employed Please provide details below: Name of Company (or JIB-PMES approved agency*) Address Telephone Number Please note: Gas Installers/Fitters/Engineers must include their CORGI operative ID number (not company registration number) on this form. If this number is not provided, the form will be returned. * For details of JIB-PMES approved labour agencies please phone or visit the website

12 Section 11b Plumbing Related Occupations White Card Name National Insurance Number Health & Safety Please tick against safety qualifications obtained: CITB Health & Safety test Other Approved Safety Course Please ensure you send copies of your test/course certificates with this application. SECTION 11b: Plumbing Related Occupations White Card Please tick the box which best describes your occupation (Tick one box only) Pump Installer Flue Fitter/Installer Solar Heating Installer CCTV Drainage Supplier Water Irrigation System Installer RPZ Valve Engineers Fuel Tank, Pipework and Fuel Pump Installer Laundry Equipment Installer Unvented System Installers Medical Gas Services Installer/Engineer Chlorination and Disinfection Equipment Installer Lead Worker (and other sheet weathering) Installer The above list is not exhaustive. If your occupation is not covered please describe the job role you perform and include any copies of certificates that are applicable. EMPLOYER S DECLARATION I certify that the details provided by the applicant are correct to the best of my knowledge.the applicant has been known to me for years Name of Employer/Company Address Address Telephone Number Signed Date D D M M Y Y Y Y / / Print Name Position in Company

13 Section 12 Plumbing Employee Card Name National Insurance Number Health & Safety Please tick against safety course evidence included with application JIB-PMES/CITB Health & Safety test Other Approved Safety Course The applicant is employed as: Plumbers mate General Operative Labourer Note: The occupation of the card holder will appear on the reverse of the card. Please note that this card is not open to Plumbers, Heating Fitters or Pipe Fitters who must meet the requirements for Blue or Gold Cards. I confirm that the applicant has demonstrated the competence that meets the minimum standards for the occupation stated above Name of Employer/Company/JIB-PMES approved agency* Address Signed Telephone Number Print name Position in Company/Agency * For details of JIB-PMES approved labour agencies please phone or visit the website

14 Section 13 Plumbing, Heating Fitter or Mechanical Pipefitting Apprentice/Trainee Health & Safety Please tick against safety course evidence included with application NVQ/SVQ Exemption JIB-PMES/CITB Health & Safety test Name Other CITB Approved Safety Course National Insurance Number Section 13a: Complete this Section if you are an Apprentice or Trainee DETAILS TO BE REGISTERED To request your Trainee card, please indicate the National/Scottish Vocational Qualification which you are undertaking: Name of qualification: NVQ/SVQ Level 2 NVQ/SVQ Level 3 NVQ/SVQ Registration Number Start Date of NVQ/SVQ D D M M Y Y Y Y / / SECTION 13b: To be completed by College/Training Centre Tutor/Lecturer If you are claiming exemption from the JIB-PMES Health and Safety test the following needs to be completed by your tutor/lecturer: I certify that the applicant named above has successfully completed the appropriate NVQ unit(s) providing exemption from the JIB-PMES Plumbing and Gas health and safety test. Signed (by tutor/lecturer) D D M M Y Y Y Y Date / / Your Name Job Title Name of College/Training Centre

15 Section 13 Plumbing, Heating Fitter or Mechanical Pipefitting Apprentice/Trainee PLEASE GIVE THIS FORM TO YOUR EMPLOYER TO COMPLETE SECTION 13c SECTION 13c: To be completed by Employer of Apprentice or Trainee EMPLOYER S DETAILS AND ENDORSEMENT The Apprentice/Trainee shall undertake recognised training or pursue accreditation of learning and/or experience with a view to achieving a Level 2 or Level 3NVQ/SVQ in Plumbing, Heating Fitting or Mechanical Pipefitting.By endorsing this application for a JIB-PMES CSCS Card as an Apprentice/Trainee, I confirm that the applicant and the employer have entered into an individual partnership arrangement to ensure the applicant has every opportunity to undergo periodic assessment of his knowledge and experience, and gather evidence to prove his normal day-to-day working experience. I also certify that the applicant named above has been employed by this company since D D M M Y Y Y Y / / Signed (by employer) Your Name D D M M Y Y Y Y Date / / Position in Company Name of Employer/Company Address Address Telephone Number

16 Section 14a PMES Supervisor SECTION A Health & Safety Please tick against safety qualifications obtained: NVQ/SVQ Exemption Other Approved Safety Course JIB-PMES/CITB Manager Health & Safety test Please ensure you send copies of your test/course certificates with this application. SECTION B For industry accreditation and NVQ/SVQ applicants. Your immediate manager or Director must complete this section. The applicant must not sign this section. I confirm that the applicant has had at least one-year on-site experience or other experience appropriate to the occupation listed above, after initial training.i agree that the applicant has demonstrated competence that meets the minimum standards overleaf and recommend the issue of a card. I certify that the details on this form are correct to the best of my knowledge. I have known the applicant for year(s). Company name (if applicable): Address: JIB-PMES Reg No. if applicable: - Telephone number: Print name: Position: Address: Signature:

17 SECTION C For industry accreditation and NVQ/SVQ applicants. Your immediate manager or Director must complete this section. The applicant must not sign this section. I confirm that the applicant has had at least one-year on-site experience or other experience appropriate to the occupation listed above, after initial training. I agree that the applicant has demonstrated competence that meets the minimum standards overleaf and recommend the issue of a card. I certify that the details on this form are correct to the best of my knowledge. I have known the applicant for year(s). Company name (if applicable): Address: Telephone number: JIB-PMES Reg No. if applicable: Print name: Professional status/qualifications: Address: Signature: Please send a VAT receipt

18 THE FOLLOWING IS A GUIDE TO THE MINIMUM ACTIVITIES A COMPETENT PLUMBING/MECHANICAL ENGINEERING SERVICES SUPERVISOR WOULD BE EXPECTED TO PERFORM TO ACHIEVE INDUSTRY ACCREDITATION 1. Plan site work Determine and agree work methods Determine and agree work programmes 2. Implement site work Inspect and prepare the workplace Implement work organisation and communications systems 3. Contribute to maintaining resources for work Contribute to the deployment and use of materials Contribute to the deployment and use of plant and equipment Assist in obtaining the workforce 4. Monitor and control work Monitor and control the progress of operations Monitor and control work quality Maintain dimensional control of work 5. Establish and maintain a safe and healthy workplace Establish the conditions for a safe and healthy workplace Maintain a safe workplace 6. Create effective working relationships Gain the trust and support of colleagues and team members Gain the trust and support of one s immediate manager Minimise team conflict 7. Contribute to establishing and maintaining relationships with customers and the community Contribute to establishing and maintaining relationships with customers Contribute to establishing and maintaining relationships with the community Before sending your form please check that it has been fully completed.your form will be sent back if it has not been properly filled in. If you need help with your form, telephone the helpdesk on Please send your form, photocopies of certificates and payment by cheque or postal order (made payable to JIB-PMES) to: JIB-PMES, Lovell House, Sandpiper Court, Phoenix Business Park, Eaton Socon, St. Neots, Cambridgeshire PE19 8EP

19 Section 14b PMES Manager SECTION A Health & Safety Please tick against safety qualifications obtained: NVQ/SVQ Exemption Other Approved Safety Course JIB-PMES/CITB Manager Health & Safety test Please ensure you send copies of your test pass/course certificates with this application. SECTION B For industry accreditation and NVQ/SVQ applicants. Your immediate manager or Director must complete this section. The applicant must not sign this section. I confirm that the applicant has had at least one-year on-site experience or other experience appropriate to the occupation listed above, after initial training.i agree that the applicant has demonstrated competence that meets the minimum standards overleaf and recommend the issue of a card. I certify that the details on this form are correct to the best of my knowledge. I have known the applicant for year(s). Company name (if applicable): Address: JIB-PMES Reg No. if applicable: Telephone number: Print name: Position: Address: Signature:

20 SECTION C For industry accreditation and NVQ/SVQ applicants. Your immediate manager or Director must complete this section. The applicant must not sign this section. I confirm that the applicant has had at least one-year on-site experience or other experience appropriate to the occupation listed above, after initial training. I agree that the applicant has demonstrated competence that meets the minimum standards overleaf and recommend the issue of a card. I certify that the details on this form are correct to the best of my knowledge. I have known the applicant for year(s). Company name (if applicable): Address: JIB-PMES Reg No. if applicable: Telephone number: Print name: Professional status/qualifications: Address: Signature: Please send a VAT receipt

21 THE FOLLOWING IS A GUIDE TO THE MINIMUM ACTIVITIES A COMPETENT PLUMBING/MECHANICAL ENGINEERING SERVICES MANAGER WOULD BE EXPECTED TO PERFORM TO ACHIEVE INDUSTRY ACCREDITATION 1. Manage project briefs Agree and present a project brief Advise stakeholders on project cost strategies Prepare a schedule which meets the requirements of the project brief 2. Assess and manage project risks Assess project risks Specify and implement methods and procedures to manage project risks Manage project health, safety and welfare 3. Establish and monitor project teams Select and form a project team Establish and monitor project team working methods Establish and monitor project organisation and communication systems 4. Control project cost, quality and progress Control project costs against agreed budgets Control project against agreed quality standards Control project progress against agreed schedules 5. Co-ordinate project handover and evaluation Co-ordinate provision of information and guidance to support operation of the works and installations Manage project completion and handover Evaluate projects Plus any 3 of the following 6 6. Establish criteria for project briefs Agree client requirements and preferences Assess user needs and options Assess community factors 7. Evaluate and advise on development factors and potential design solutions Evaluate development opportunities, constraints and potential solutions Advise on potential options for development 8. Advise on and co-ordinate project design development Advise stakeholders on the selection and modification of design Facilitate the agreement of a detailed design Manage the flow of design documents 9. Advise on and secure statutory consents Advise on regulatory requirements and constraints Confirm statutory control requirements and consent applications Manage appeals and negotiate to secure statutory consent 10. Agree procurement and contract procedures Select and agree a project procurement procedure with a client Evaluate and agree potential tenderers Select, recommend and agree a form of contract 11. Implement tenders and conclude contracts Implement estimate, bid and tender procedures Evaluate successful tenders and negotiate changes Conclude a contract for the supply of works, goods, materials and consultancy services Plus any 3 of the following Select personnel for activities Identify personnel requirements Select required personnel 13. Manage the performance of teams and individuals Allocate work to teams and individuals Agree objectives and work plans with teams and individuals Assess the performance of teams and individuals Provide feedback to teams and individuals on their performance 14. Enhance working relationships Develop and maintain relationships with stakeholders Enhance the trust and support of colleagues Enhance the trust and support of those to whom you report Provide guidance on values at work 15. Advise on problems and solutions Collate information and provide advice on technical problems Re-frame and generate solutions to complex, indeterminate problems 16. Chair and participate in meetings Chair meetings Participate in meetings 17. Develop self and others Optimise your own resources to meet objectives Undertake personal development in the occupational practice area Enable others to learn and benefit from one's experience Important note:- Achievement of an NVQ Level 4 does not exempt the holder from the Managers Health and Safety Test.Before sending your form please check that it has been fully completed.your form will be sent back if it has not been properly filled in. Before sending your form please check that it has been fully completed.your form will be sent back if it has not been properly filled in. If you need help with your form, telephone the helpdesk on Please send your form, photocopies of certificates and payment by cheque or postal order (made payable to JIB-PMES) to: JIB-PMES, Lovell House, Sandpiper Court, Phoenix Business Park, Eaton Socon, St. Neots, Cambridgeshire PE19 8EP

22 Section 15 Site Visitor Card Name National Insurance Number SECTION 16: Site Visitor Card Health and Safety Testing/Training Occupation Recognised JIB-PMES CSCS/CITB Health and Safety Test Title of Test Taken Date test taken D D M M Y Y Y Y Certificate Number / / Please attach your Test Certificate or Pass Letter EMPLOYER S DECLARATION I certify that the details provided by the applicant are correct to the best of my knowledge and that the photograph is a true likeness of the applicant who has been known to me for years Name of Employer/Company Address Address Telephone Number Signed Date D D M M Y Y Y Y / / Print Name Position in Company