Electrical Contractor Notice of Change of Field Safety Representative Form 1023

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Please refer to our website or contact a Regional Office to locate the BC Safety Authority office nearest you. Coquitlam Kelowna Nanaimo Victoria 604-927-2041 250-861-7313 250-716-5200 250-952-4444 fax 604-927-2047 fax 250-861-7349 fax 250-716-5212 fax 250-952-4458 fax 778-396-2174 Kamloops Langley Prince George 250-314-6000 604-539-3573 250-614-9972 fax 250-377-4406 fax 604-539-3570 fax 250 614 9949
New Westminster
505 - 6th Street, Suite 200, New Westminster, BC, V3L 0E1
Website: www.safetyauthority.ca fax 1-888-660-3508
Local Phone: 778-396-2000
Toll Free: 1-866-566-SAFE (7233)
The information on this form is collected to administer the provisions of the Safety Standards Act. If you have questions about the collection, use or disclosure of this information, contact the Records, Information & Privacy Analyst at 1-866-566-SAFE (7233). The fee for replacement card(s) is waived if the Electrical Contractor attaches this notice to their Electrical Contractor Renewal Notice Reminder. Replacement Fee:
For completion by company representative: Electrical contractor’s license no.: _____________________________________________________________________________________ Business Name: ___________________________________________________________________________________________________ Mailing Address: ___________________________________________________________________________________________________
Suite No. Street No. Street Name Street Type
City: __________________________________________ Telephone: ( )
Province: __________________ Postal Code: ________________________ Fax: ( )
I, _________________________________________________________ request the following change of Field Safety Representative (FSR) Authorized Company Representative - Print be made effective as of:
YYYY MM MM DD DD FSR Registration Number
Signature Authorized Company Representative Delete Field Safety Representative YYYY FSR Class(es)
I have destroyed the existing Electrical Contractor Identification Card(s) for the FSR being deleted. I require ___________ new card(s).
Add Field Safety Representative FSR Class(es) FSR Registration Number
For completion by new Field Safety Representative (FSR) representing the electrical contractor:
FSR Name (please print) FSR Contact Telephone Number Home Address (Suite # - Street # - Street) FSR Class(es) Optional Contact (Cell no.) City Prov. Postal Code FSR Registration No.
I have read and understand my duties, requirements and restrictions under the Safety Standards Act, Safety Standards General Regulation and the Electrical Safety Regulation to be the designated Field Safety Representative (FSR) named on the license for the electrical contractor above. I am registered as a Field Safety Representative and hold a valid and subsisting FSR Certificate of Qualification with the class(es) as noted. I am employed by and will represent only this one contractor in this capacity. Date: FSR Signature Accepting Appointment YYYY MM DD Unless otherwise noted, this Form is to be completed, attached to an ELECTRICAL GENERAL TRANSACTION FORM with applicable payment of fee and mailed to Customer Services Department at an address noted above.
For office use only:
I have verbally confirmed the acceptance of the Field Safety Representative position with the above named Field Safety Representative. Name of CSR or Electrical Safety Officer Office: Fee: $ Processed by: Signature Technology: EL Payment method: Payment date: YYYY MM DD File No: Date: YYYY / MM / DD
FRM-1023-05 (2009-05-04)