Title Page
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Site conducted
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Conducted on
Worker Information
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Name
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Employment Status
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Company
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Company
Declaration
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I will immediately notify RoadTek and provide details of any loss of licence, infringement, or contravention of the Transport Operations (Road Use Management) Act 1995 and the National Heavy Vehicle Law Act 2012 and subordinate regulations whilst driving a vehicle for RoadTek. This includes charges or infringement notice issued by a police officer or transport inspector of the Department of Transport and Main Roads.
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RoadTek Witness (MUST sight evidence detailed on this form and sign below as witness)
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I verify that I have sighted the current driver / industry licence or competency documentation, and all details are correct.
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Position
Drivers Licences
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Drivers Licence Type
- L Learner
- P1 / P2 Provisional
- C Car
- LR Light Rigid
- MR Medium Rigid
- HR Heavy Rigid
- HC Heavy Combination
- MC Multi Combination
- Commercial marine licence
- Recreational marine licence
- DG Dangerous Goods
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Licence Number
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Condition Codes
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Expiry date
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Issuing State
- QLD
- NSW
- VIC
- SA
- WA
- TAS
- ACT
- NT
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Will the driver be operating under RoadTek's AFM Accreditation?
Licences & Competencies
- Industry Licences & Competencies
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Industry Licence type
- White or Blue Card
- TC Traffic Controller
- TMI Traffic Management Implementation
- TMD Traffic Management Design
- Confined Space
- Working at Heights
- Electrical Work Licence Mechanic & Fitter
- Electrical Work Licence Mechanic (Fitter only not enough for RT Work)
- Electrical Work Licence Restricted
- Electrical Contractors
- LVR (Low Voltage Rescue)
- First Aid (Apply First Aid)
- CPR (Provide cardiopulmonary resuscitation)
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Licence / Card #
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Effective Date
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Expiry Date
High Risk Work Licence
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Licence type
- WP Work Platform (EWP) Boom (11m or more)
- C1 Slewing Mobile Crane
- C2 Slewing Mobile Crane
- C6 Slewing Mobile Crane
- CN Non-slewing Mobile Crane
- CV Vehicle Loading Crane
- LF Forklift Truck
- DG Dogger
- Rigger
- Scaffolder
- BL Self-propelled boom lift
- VL Vertical lift
- SL Scissor Lift
- T Transporting
- TL Trailer mounted boom lift
- TM Truck mounted boom
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Type
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Type
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Licence / Card #
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Effective Date
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Expiry Date
Verification of Competency (VoC) Plant Operators & Movers
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Plant Item
- LB Backhoe Front End Loader
- LE Excavator
- LG Grader
- LL Front-end loader
- LP Scraper
- LR Road Roller
- LS Skid Steer loader
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Card type
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Card Number
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Issue Date
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Review Date
