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NSW Resources Regulator

FORM

Certificate of competence

Stage 1 - application for a certificate of competenceMay 2023

Work Health and Safety (Mines and Petroleum Sites) legislation

1.OverviewUnder the Work Health and Safety (Mines and Petroleum Sites) Regulation 2014 a person is eligible to hold a certificate of competence in respect of a statutory function if the regulator is satisfied that the individual is competent to exercise that function.

The certificate of competence guide includes information about eligibility to be granted a certificate and the processes involved in assessing whether a person is competent to be issued a certificate.

2.Instructions You must read the guide before completing this application form.

Your application must be accompanied by supporting documents to evidence that you satisfy each of the prerequisite qualifications and the identity verification. All documentation must be certified by an independent authorised certifier.

No fee is payable when lodging this Stage 1 – application.

If this Stage 1 – application is satisfactory, you will be invited to progress to the Stage 2 – written examination. You will then be notified of fees and payment options.

Information about lodging your application is provided at the end of this application form.

A separate form must be submitted for each certificate of competence you are seeking to apply for.

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FORMCertificate of competence

3.Personal detailsDetail required Complete details here

First name/s*

Last name*

Preferred name

Salutation Mr Mrs Ms Miss Dr Other

Gender Male Female Other

Date of birth(DD/MM/YYYY)

Place of Birth(town/city, state)

Country of Birth (if other than Australia)

Home address(inc. suburb and postcode)

Postal address(inc. suburb and postcode)

Personal email address

Work email address

Home telephone

Mobile

Current place of employment**

* Provide your full legal name.** Only required if you are currently employed at a mine.

NOTE: Details of the examination process, i.e. invitations to sit exams, payment forms and notification of examination results, will be emailed to your nominated email address(es). If you are deemed competent your certificate of competence will be sent to your nominated postal address. Please keep your contact details up to date with the mining competence team.

4.Certificate of competence for a statutory function

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Please select one statutory function that you are applying for examination of a certificate of competence for:

Underground coal mines

Mining engineering manager of underground coal mines

Electrical engineering manager of underground coal mines

Mechanical engineering manager of underground coal mines

Undermanager of underground coal mines

Deputy of underground coal mines

Coal mines other than underground coal mines

Mining engineering manager of coal mines other than underground coal mines

Open cut examiner of coal mines other than underground coal mines

Electrical engineer of coal mines other than underground coal mines

Mechanical engineer of coal mines other than underground coal mines

Underground mines other than coal mines

Mining engineering manager of underground mines other than coal mines

Underground mine supervisor of underground mines other than coal mines

Mines other than underground mines or coal mines

Quarry manager of mines other than underground mines or coal mines

NOTE: You can only use this form to apply for re-examination of a certificate of competence for one statutory function. A separate re-examination form must be submitted for each certificate of competence.

5.Practising certificate for a statutory function If you are found competent to exercise the statutory function selected above, would you like a practising certificate issued at the same time as your certificate of competence?

Yes

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No

Have you previously been issued with a Practising Certificate?

Yes

No

If yes, please provide details of the practising certificate for a statutory function that you currently hold. If various, please list all documents below.

Statutory function: Practising certificate number:

Issue date:

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6.Practical experienceProvide evidence showing you have the appropriate practical experience by completing the table below. You must provide details of practical experience, including the nature of the work undertaken and the name and suburb of the operation(s). Once completed, this table should reflect the practical experience requirements set out in section 5.2 of the guide.

NOTE: By providing reference contact information, you are permitting the department (and any persons engaged for the purposes of managing certificates of competence and practising certificates) to contact your referees to confirm your experience.

Date:From (DD/MM/YY)

Date:To (DD/MM/YY)(must be actual date, not current or present)

Period of experience(years, months)

Experience (including position held and job tasks performed)

Mine and company details

Full name, signature and position title of your supervising manager and date signed (DD/MM/YY)

Contact details

** For more space when completing the form, please print this page as many times as required or utilise the fillable (word version) located on the website. The fillable form allows the boxes to expand as more information is entered.

Total experience (please calculate): years_ months

Full legal name:

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7.Tertiary qualificationsComplete the table below and attach a certified copy of your tertiary qualifications and any statements of attainment or transcripts listing the subjects completed. See section 8 ‘of the guide for ‘How to certify documents’.

Qualification Institution/training organisation Date of issue

8.Prequalification examination details (only available for certain statutory functions)

If you are applying for a certificate of competence for a mining engineering manager and/or an undermanager of underground coal mines, and you do not hold the required tertiary qualifications, complete the table below and attach a certified copy of your prequalification examination result letter. See section 8 of the guide for ‘How to certify documents’.

Name Date of Pass of final paper (MM/YYYY)

9.Current first aid certificate

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Complete the table below and attach a certified copy of your first aid certificate that is current at the date of the written and oral examination. See section 8 of the guide for ‘How to certify documents’.

Qualification Institution/training organisation Date of issue

10.Emergency preparedness unit of competence Complete the table below and attach a certified copy of your emergency preparedness unit of competence or the qualification which lists it. See section 8 of the guide for ‘How to certify documents’.

Unit of competence or qualification Institution/training organisation Date of issue

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11. Blasting experience (only required for quarry managers)If you are applying for a certificate of competence for a quarry manager of mines other than underground mines or coal mines, you must either:

complete the table below to demonstrate that you have the required blasting experience. The table must include the details and licence number of the supervising shotfirer under which you have gained the experience, or

attach a certified copy of both sides of your current Blasting Explosives User’s Licence (BEUL) (issued by SafeWork NSW) for use in above ground mining, if you are the licence holder. See section 8 of the guide for ‘How to certify documents’.

Date(DD/MM/YY)

Mine and location

Type of Blaste.g. dropcut, production

Quantity of Explosives (kg)

No. of Holes

Diameter of Holes(mm)

Av. depth of holes(m)

Outline of participation in blasting operation

Supervising shotfirer’s Name, contact details, & BEUL number

Shotfirer’s Signature & Date

Date(DD/MM/YY)

Mine and location



No. of Holes






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Date(DD/MM/YY)

Mine and location



No. of Holes






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12. Identity verification documentsPlease tick the boxes below to indicate which documents are attached to your application. You must attach a certified copy of all the documents provided. See section 8 of the guide for ‘How to certify documents’.

Group A documents - Must have name, date of birth and place of birth

Birth certificate

Citizenship certificate

Current passport

Expired passport that has not been cancelled and was current within the preceding two years

Other documents of identity having the same characteristics as a passport including diplomatic documents and some documents issued to refugees

Group B documents - Must have photograph, name and current residential address

Driver’s licence issued by an Australian state or territory

Roads and Maritime Services (formerly RTA) photo card

Identification card issued to a public employee

Identification card issued by the Commonwealth, a State or Territory government as evidence of the person's entitlement to a financial benefit

13.Application checklistApplications will only be processed if the required details are provided and documentation to accompany the application is received and certified as a true copy by an authorised certifier who is an independent third party. See section 8 of the guide for details.

Have you completed all details in each column of your practical experience and had it signed?

Have you included certified copies of evidence of your mining qualifications, including the

transcript/statement of subjects completed or a statement of equivalence? (Note: this does not apply if

your mining qualification is a pass in the prequalification examination.)

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Have you included a certified copy of your first aid certificate, current at the dates of

examination?

Have you included a certified copy of your emergency preparedness unit of

competence/qualification?

Have you completed your practical blasting log of experience table and had it signed or included

a certified copy of both sides of your Blasting Explosives User’s Licence? (Note: This is only required for

applications for certificate of competence for a quarry manager of mines other than underground mines or coal mines).

Have you included certified copies of your identity verification documents?

DeclarationI declare that:

to the best of my knowledge, the information provided in this form and any attachment(s) to this form, is true and correct in every detail

I consent to the Department of Planning and Environment disclosing my personal information to the Mining and Petroleum Competence Board and any persons engaged for the purposes of managing certificates of competence and practising certificates under the Work Health and Safety (Mines and Petroleum Sites) Act 2013 and the Work Health and Safety (Mines and Petroleum Sites) Regulation 2014.

Name

Position/title

Contact telephone

Mobile

Signature

Date

NOTE: Giving false or misleading information is a serious offence under section 268 of the Work Health and Safety Act 2011, and Part 5A of the Crimes Act 1900.

Clause 150 of the Work Health and Safety (Mines and Petroleum Sites) Regulation 2014 provides for the cancellation of a certificate of competence if the certificate was improperly obtained, whether on the basis of false or misleading information.

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Submitting the formYour application must be complete when submitted or it will be returned.

Complete applications must be received by the examination closing date or they will be rejected.

We prefer that applications be submitted via email. Alternatively, you may mail or fax your application to us. Please only submit your application via one method.

Email: [email protected] (preferred option)

Mail: Mining Competence Team, NSW Department of Planning and Environment, PO Box 344, HRMC NSW 2310

© State of New South Wales through the NSW Department of Planning and Environment 2018.

This publication is copyright. You may download, display, print and reproduce this material in an unaltered form only (retaining this notice) for your personal use or for non-commercial use within your organisation. To copy, adapt, publish, distribute or commercialise any of this publication you will need to seek permission from the NSW Department of Planning and Environment.

Disclaimer: The information contained in this publication is based on knowledge and understanding at the time of writing (May 2023). However, because of advances in knowledge, users are reminded of the need to ensure that information upon which they rely is up to date and to check currency of the information with the appropriate officer of the NSW Department of Planning and Environment or the user’s independent advisor.

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