EW Number

Registration/Registration Certicate/Practising Licence Application

Please see the back of the form for additional information. Please print clearly in black or blue pen and complete all required sections of the form.

Personal Details
Last Name First Name Middle Name Date of Birth Home Phone ( D D ) / M M / Y Y Y Y Work ( ) Mobile ( Postcode ) Email Street address

What Electrical Class you are applying for

1. Electrical Inspector Electrician Electrical Installer 2. Please specify what you are applying for Registration Certicate Registration only Practising Licence Electrical Appliance Serviceperson Electrical Service Technician Line Mechanic Cable Jointer Electrical Engineer AT Plumber AT Gastter AT Plumber & Gastter

Information supporting the application

3. Safety Training required for Registration Safe Working Practices, Testing, Basic First Aid and CPR, MUST have been completed during your training towards electrical registration. Where (name of training provider) Date completed (Day/Month/Year) D D / M M / Y Y Y Y

Note: If safety training for registration has been completed in the last 24 months you are not required to complete section 4 of this form. ALL OTHER APPLICANTS MUST COMPLETE BOTH SECTION 3 AND 4 OF THIS FORM 4. Competency Programme training required for Licence Where (name of training provider) Electrical Safety First Aid CPR Date completed (Day/Month/Year) D D D Electrical Safety First Aid CPR Electrical Safety First Aid CPR Electrical Safety D D D / / / M M M M M M / / / Y Y Y Y Y Y Y Y Y Y Y Y

Electrical Inspector, Electrician, Electrical Engineer, Electrical Installer, Electrical Service Technician Electrical Appliance Serviceperson, Associated Tradesperson

Every 2 years Every 2 years Every 2 years Every 14 months Every 14 months Every 7 months Every 14 months

Line Mechanic, Cable Jointer All classes of registration engaged in Works denition of works is: Any ttings that are used, or designed or intended for use, in or in connection with generation, conversion, transformation, or conveyance of electricity.

Note: If safety training for your licence application has been completed in the last 24 months, the training is able to be considered as your competency programme training. 5. Please specify the type of electrical work you carry out. Appliance servicing Construction or maintenance of works Electrical wiring Servicing Installation Servicing/Maintenance Other (please specify) Works

EWRB002 02/12

Payment
6. We do not accept purchase orders or cash or postal notes. The total fee is $ (ll in amount calculated on overleaf). Payment is made by: Credit card (Credit card information completed, see overleaf) NZ Cheque made out to Electrical Workers Registration Board

Credit card information

Type Mastercard Credit Card Number Visa Amex Full Name of Cardholder

Expiry Date M M / Y Y

Amount $ Signature of Cardholder

7. Please complete the following if your application is being paid for by your employer or another party. Name/Company name Address Postcode

Declaration
I have read the information on the back of this form and certify that the information I have provided is correct. D Signature Date D / M M / Y Y Y Y

Registration requirements
New Zealand Trained Electrical Workers The registration requirements for electrical workers trained and who gained their experience in New Zealand is set out on www.ewrb.govt.nz . Australian Trained Electrical Workers New Zealand has a Trans-Tasman Mutual Recognition arrangement with Australia. This covers Australian trained and licensed electrical workers. There is a specic form to apply for this registration on www.ewrb.govt.nz . All other Electrical Workers For applicants trained outside New Zealand and Australia the information pertaining to NZ registration requirements can be found on our web site www.ewrb.govt.nz . Please be aware that when you provide your documents for assessment you will be required to complete an application for registration form and provide the registration fee. You will then be notied of what registration requirements you will need to meet and whether you are eligible to apply for a limited certicate whilst working towards gaining your registration and practising licence.

Fees
The fee for registration including the certicate is $105.29, excluding the certicate is $70.52 and certicate only is $34.76. The annual fee for a practising licence (all classes) is $94.04. However for the newly registered this is pro-rated see the table below. To work out your fee choose the month in which you are applying and put in the fee associated with that month. Add the practising licence fee to the registration fee for the total fee. Month Applied July August September October November December January February March April May June Fee 94.04 88.93 83.82 78.71 73.60 68.49 63.38 58.27 53.16 48.04 42.93 37 .81 Pay

Checklist
Have you: paid the required fee(s) attached any required certied copies of certicates (or completed EWRB exams) attached employer work experience reference(s) completed all required safety training Note: There are two qualication paths to registration for New Zealand trained and experienced persons. The rst is through having the recognised national certicates or through sitting the appropriate EWRB exams.

The fee for registration is $105.29 plus the pro-rated practising licence fee from the table above. Registration (excluding certicate) Registration (including certicate) Practising Licence $70.52 $34.76 $ $ $ Total $

Please return this form with payment to: Electrical Workers Registration Board, PO Box 10 156, Wellington 6143, New Zealand
For more help, call our helpline on 0800 661 000 between 8 am and 5 pm Monday to Friday or email info@ewr.govt.nz.
Privacy Notice Any personal information submitted on this application will be kept and maintained by the Electrical Workers Licencing Group (the EWLG) in accordance with the New Zealand Privacy Act 1993. Personal information submitted will be used by the EWLG for determining whether applications for registration as an electrical worker or practicing licences may be granted, and for the maintenance and administration of the Electrical Workers Register. You may request access to see any information held about you and where that information is inaccurate, ask for it to be corrected.