DEPARTMENT OF OCCUPATIONAL SAFETY AND HEALTH

Level
Level 2,3
1, 3,dan 4, Block
4 and D3,D4,
5, Block Complex D, D,
Complex
Federal Government Administrative Centre, T : 03 – 88865343
62530 W.P.
62530 W.P. Putrajaya
Putrajaya F : 03 – 88892349

APPLICATION FOR REGISTRATION OF LIFT COMPETENT PERSON GRADE I/II/III

GUIDANCE NOTES :

1. This form must be completed and submitted with the application letter to the Director General of the Department
of Occupational Safety and Health at the above address.

2. Please submit the following supporting documents:

TYPE OF APPLICATION
a. Application Form Appendix 1 (new application) (Please √)
b. Application Form Appendix 4 (medical check up form)
Reference Registration No.
c. Application Form Appendix 2 (renewal application must included)
d. Application Form Appendix 3 (renewal application must included)
e. Application Form Appendix 5 (renewal application must included)
f. Application Form Appendix 6 (renewal application must included) GRADE ONE

3. A certified true copy of Identity Card.

4. Picture (passport size) GRADE TWO
5. A certified true copy of Visa or passport (Grade I only)
6. A certified true copy of BEM certificate (Grade I only)
7. The letters original declaration from the employer that shows:- GRADE THREE
i. Offer letter; and
ii. the daily tasks
8. A certified true copy of Certificate of Competency training with principal (Grade I only)
9. A certified true copy of Certificate safety and health training
10. A certified true copy of Certificate technical training related with the responsbility
11. A certified true copy of academic qualifications.
12. Resume or Curricular Vitae applicant

* Certified true copy can be done by the Commissioner of Oath or Government Officer Grade A

Please refer to Factories and Machinery (Passenger and Goods Lifts) Regulations, 1970.
 PART ONE : APPLICANT INFORMATION
1.1 Applicant Name :

1.2 Mailing Address :

1.3 Phone No. : 1.4 Fax No. :

1.5 Employer Name :

1.6 Address :

1.7 Phone No. : 1.8 Fax No. :

1.9 Registration No. of Factory/Workplace :

2.0 Registration No. of Application :

2.1 File No. of Application :

PART TWO : CERTIFICATION OF APPLICANT

I certify that the information contained in this application is the truth. The Department may reject my application if the
information is incomplete and false.

Employer's stamp
Applicant Signature : …………………………………………

Full Name : .…………………………...…………………………………….

Position : …………..………………...…………………………………….

Date : ………………...…………………………………….

Date updated : 23rd Disember 2011

 Appendix 1
JABATAN KESELAMATAN DAN KESIHATAN PEKERJAAN
(KEMENTERIAN SUMBER MANUSIA)
APPLICATION TO BE REGISTERED AS A LIFT COMPETENT PERSON I/II/III

A. PARTICULARS OF THE CANDIDATE

(To be filled by the Applicant)
1. PERSONAL PARTICULARS
1.1 Name of Candidate (in block letters) 1.2 Date of Birth
…………………………………………………. ………………………

1.3 Sex 1.4 Identity Card Number*

Male Female ……………………………………….
1.5 Place of Birth 1.6 Citizenship
……………………………………………… ………………………………….....
1.7 Approved Lift Firm Name & Registration No 1.8 Job Designations:
…………………………………………………… …………………………………….

…..……………………………………………….
1.9 Office Address 1.10 Tel. No. (Office)

…………………………………………………… ………………………………………..

……………………..…………………………… 1.11 Tel. No. (Home)

………………………………………..
1.12 E-mail Address

.............………………………………..
2. QUALIFICATION
2.1 Professional education*
Name of Institution Year Qualification
/University (From – To) Obtained

……………………………………. ………………. ……………………………………….

……………………………………. ………………. ………………………………………

2.2 Technical training

……………………………………. ………………. ………………………………………

Date : ……………………………. ………………………..

Signature of Applicant

Note: (*) Please enclosed certified copies of relevant document and latest medical examination report.
B. EXPERIENCE OF THE CANDIDATE (To be filled by the existing CP Lift Grade I – if any)

1. TRAINING YES/NO DURATION

(a) Design …………………

(b) Manufacturing …………………

(c) Code of Practise …………………

(d) Testing/Commissioning …………………

(e) Installation …………………

(f) Maintenance …………………

(g) Other (Please specity) ………………………

2. FIELD EXPERIENCE YES/NO NO. OF MONTHS (ACCUMULATE)

(a) Design …………………

(b) Manufacturing …………………

(c) Preparation of 1st Schedule …………………

(d) Installation …………………

(e) Testing/Commissioning/ 1st Inspection …………………

(f) Maintenance/Monthly Inspection …………………

(g) Annual/Regular Inspection …………………

(h) 2nd Schedule Inspection …………………

(i) Total number of year experiences in lift industry ………………………

C. DECLARATION BY THE CP Lift Grade I

I hereby:-
i. certify that the above particulars are true and correct to the best of my knowledge; and
ii. declare that all of the conditions as set out in paragraph 2 have been fulfilled.

Date : ……………………………. ……………………………

Signature
( Name of CP Lift Grade I )
CP Lift Grade I No :………….