RSW Card Application and 100 Point ID Form - RailSafe

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RSW Card Application and 100 Point ID Form - RailSafe

84. FORM: RSW Card Application and 100 Point ID Form

IMPORTANT: Please complete both pages of this form

Completed forms and attachments should be sent to RCT_competencycards@railcorp.nsw.gov.au or

RSW Cards, PO Box 202, Petersham NSW 2049.

Contractor Details

Name:

Address:

Phone Number:

Email:

Date of Birth:

Postcode:

Do you hold a current or expired RailCorp RSW card? Yes No

Is this application for an Engineering Authority?

Yes, please specify discipline (Tick ONLY one option)

Note - If you are applying for Engineering Authority for the FIRST time you must

complete this form. If you have completed this form for a previous Engineering Authority

you do NOT need to fill this form in again.

You do not need to complete this form if you are Level 3 (working under supervision).

Civil Electrical Geotechnical

Rollingstock Signals & Control Systems Stations & Buildings

Surveying Telecommunications Track

Company Details – if applicable

Company Name:

Address:

Please indicate preferred method of card distribution

by ticking a box:

Address for RailCorp card to be sent to:

Questionnaire

Postcode:

© 2012 Rail Corporation New South Wales

Business Process Owner: General Manager, Learning & Development

QTMS FO84 v7 RSW Card Application and 100 Point ID Form

Effective Date: September 2012

Printed copies are uncontrolled Page 1 of 3

No

Card to be collected Mail

Postcode:

Tick box for

response

1. Have you ever been an employee of RailCorp, State Rail Authority or Rail Infrastructure

Corporation? Yes No

If Yes, please provide details below:

Employee no. (if available):

2. In the last 5 years have you recorded a positive drug test at any workplace or at a

work-related health assessment? Yes No

If Yes, please provide details below:

Times recorded

a positive

reading

First

Second

When Where What was the substance detected?


Questionnaire

Tick box for

response

3. In the last 5 years have you recorded a positive alcohol test at any workplace or at a

work-related health assessment? Yes No

If Yes, please provide details below:

Times recorded

a positive

reading

First

Second

When Where

What was the

reading?

Was the reading considered:

Low

Range

Mid

Range

4. In the last 3 years have you recorded a positive test for drugs or alcohol leading to a

conviction under any law? Yes No

If Yes, please provide details below:

Drugs When

What was the result?

Alcohol When

What was the result?

5. If you answered Yes at Question 2, 3 or 4, did you inform the assessing doctor of the

previous positive test(s) at your recent contractor health assessment?

Yes No

6. Have you previously been issued with a track safety authority, track safety awareness

(TSA), rail industry safety induction card (RISI) or rail safety worker (RSW) card?

If Yes, please provide details below:

Card Number (if available):

Yes No

Card Acceptance Agreement

On receipt of this card, I the Card Holder hereby undertake to:-

� Ensure that all information on the card including the name and photo is accurate

� Sign the back of the card immediately upon receipt of the card if the information is accurate

� Ensure all health conditions required under the card will be adhered to

� Comply with all work procedures and requirements set by RailCorp including all requirements relating to

fatigue, drug and alcohol, health and fitness

� Carry the card with me whenever on or about the track

� Notify RailCorp of any changes which may affect the accuracy of the matters attested to in the card

� Physically destroy my previously issued card

� Return this card to RailCorp if requested to do so by RailCorp and acknowledges that this card remains the

property of RailCorp at all times.

I agree to the card acceptance agreement above, state that the documents presented are originals or

certified copies, that this is my true identity, and that all information supplied is accurate.

Signature:

Date:

High

Range

Checklist for applicants/card holders

A minimum of 100 points of identification provided, using both primary and secondary document categories

All documents provided are originals that have been sighted by a RTO representative, or copies certified by a

JP or equivalent

You have completed all sections of this form and signed the form

� 2012 Rail Corporation New South Wales

Business Process Owner: General Manager, Learning & Development

QTMS FO84 V7 RSW Card Application and 100 Point ID Form Effective from: September 2012

Printed copies are uncontrolled Page 2 of 3


100 Point Identification & Quality Check Form

� You can only use ONE primary document

� Your current or expired RSW card cannot be used as proof of identity

� You must include ONE form of photo ID

Copies of your ID can be certified as true and correct copies of the originals by a:

� Approved RailCorp RTO Representative

� Justice of the Peace

� Accounting professional (CPA or equivalent)

Primary Documents (certified copy or original to be provided)

Points Document Type

70

You can only use ONE

primary document

Office Use Only

Document no:

Birth Certificate

Citizen Certificate

Current Passport

� Legal practitioner

� Police employee

� Agent of Australia Post with two or more years

continuous service

Expired passport which has not been cancelled and was current within the preceding 2 years

Driver’s licence issued by an Australian State or Territory

NSW Photo Card or Proof of Age Card issued by the RTA

Secondary Documents (document to be sighted and recorded)

Original

sighted/copy

certified

Points Document Type Original sighted

40

Licence or permit issued under a law of the Commonwealth, a State or Territory Government

Must have a

photograph and a

Identification card issued to a public employee

name

Identification card issued by the Commonwealth or a State or Territory Government as evidence of

entitlement to a financial benefit

35

Must have a name and

address

25

Must have a name and

signature

25

Must have a name and

address

An identification card issued to a student at a tertiary education institution

A mortgage or other instrument of security held by a financial body

Council rates notice

Land Titles Office record

Marriage Certificate

Credit card

Foreign Driver’s Licence

WorkCover Licence / Certificate

Medicare card (signature not required)

Membership to a Registered Club

NRMA Membership

EFTPOS card

Document from your current employer or previous employer within the last 2 years

Records of a public utility—phone, water, gas, or electricity bill

Records of a financial institution

A record held under a law other than a law relating to land titles

Lease/rent agreement

Rent receipt from a licensed real estate agent

25

Record of a primary, secondary or tertiary education institution attended within the last 10 years

Must have a name and

date of birth Record of professional or trade association of which you are a member

100 Points of Identification confirmation

Name:

Signature:

Company:

� 2012 Rail Corporation New South Wales Business Process Owner: General Manager, Learning & Development

QTMS FO84 V7 RSW Card Application and 100 Point ID Form Effective from: September 2012

Printed copies are uncontrolled Page 3 of 3

Date:

Phone Number:

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