Professional Membership Renewal Application For Renewal of Professional Membership Name(Required) First Last Will be listed in Member Profile on Website.Date(Required) DD slash MM slash YYYY Email(Required) Will be listed in Member Profile on Website.Mobile/Phone(Required)Will be listed in Member Profile on Website.PhoneBusiness Number if different. Will be listed in Member Profile on Website.Business Website Will be listed in Member Profile on Website.Personal InformationNote: No personal information will be listed on the HSPNZ website. The notes on this form identify what information will be displayed on the HSPNZ Members listing.Gender(Required)MaleFemaleNon-binaryAgenderMy gender is not listedPrefer not to answerDate Of Birth(Required) MM slash DD slash YYYY PhotoMax. file size: 128 MB.Please provide a photo you would like used on the website. Preferably 190 x 190px.Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employer or Business/Company InformationNote: Some of the below information will be listed on the HSPNZ website. If a required field is not applicable to you identify why not or enter N/A.Professional Approval Number(Required) Enter N/A if this is not applicable. For Compliance Certifiers this will be your WorkSafe Authorisation Number. Other Professional Body's will have their own version of this.Industry You Are Working In(Required) Your Current Position(Required) Other Affiliations or Associations You Are A Member Of?In case of a conflict of interest.Business Name(Required) Will be listed in Member Profile on Website.Name First Last Owner, employer, supervisor, manager if different.Email If different to above.PhoneIf different to above.PO Box/Postal/Business Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Will be listed in Member Profile on Website. Profile InformationCompliance Certifiers - Scope of Authorisation(Required) Not a Compliance Certifier Approved Fillers Approved Fillers - LPG Cylinders only Blast over Pressure and Hazard Certified Handler - Agrichemicals Certified Handler – Class 1 Certified Handler – Class 6 Certified Handler – Fumigants Certified Handler – Vertebrate Toxic Agents (VTA) Container (Magazine) Design Container (Readily Movable Container) Construction Cylinder Design Verification Cylinder Importation Cylinder Importation (UN) Cylinder Pre-Commissioning Detonation and Deflagration in Darkness Existing Stationary Container Systems Compliance Plan Location – Class 1 Location - Classes 2 & 3.1 Location – Classes 2, 3.1 & 5 Location - Class 3.1 Location - Classes 3.2 & 4 Location – Classes 6 & 8 LPG Fittings Outdoor Pyrotechnics Display Stationary Container System – Installation Stationary Container System - Repair, Alteration & Maintenance Stationary Container System - Tanks to Burners Stationary Container System - Transfer Point pipework Stationary Container Systems Stationary Container Tank or Process Container Design Stationary Container Tank or Process Container Fabricator Tank Wagon and Transportable Container Design Tank Wagon Pre-Commissioning Tank Wagons in Service Other, please identify below: For Compliance Certifiers: This must reflect your scope of authorisation. These have already been added to your profile on the HSP NZ site - so please check this. If you have something that is not on the list or is worded differently then please let us know below. Areas of Expertise(Required) Compliance Certification Consultancy Services Consultancy Services relating to Class 1, including Storage, Transport, Use and Disposal Engineering Design Engineers - Tank design and Installation Expert Witness Expert Witness relating to Class 1 substances Field and Regulatory training Hazardous Substance Expert Witness Hazardous Substance Incident Investigation - Insurance and related matters Hazardous Substance Training Providers Hazardous Substances Consultant - Fire Evacuation Schemes to Schedule 3 Hazardous Substances Consultant - Hazardous Substances Regulations Hazardous Substances Consultant - HSWA, HSW (HS) Act, GRWM Regs etc Hazardous Substances Consultant - Risk Assessment Hazardous Substances Consultant - RMA, District and Regional Plans Health and Safety Advisor Health and Safety Consulting Independant Class 1 Location Design and Consultancy Industry Audits relating to Class 1 substances Site Plans - CAD Trainee Compliance Certifier Other, please identify below These categories will be included in your listing on the HSPNZ website. Please let us know below if you want something added.Anything not on the lists above you want added? Working Region(Required) Auckland Bay of Plenty Canterbury Gisborne Hawke's Bay Manawatu-Wanganui Malborough Nelson Northland Otago Southland Taranaki Tasman Waikato Wellington West Coast Please indicate the areas you are available to work in. Most people select all regions, but please specify the areas you are willing to work in. Will be listed in Member Profile on Website. Home Region(Required) Auckland Bay of Plenty Canterbury Gisborne Hawke's Bay Manawatu-Wanganui Malborough Nelson Northland Otago Southland Taranaki Tasman Waikato Wellington West Coast This is the region you are actually based in. You can only pick one. Will be listed in Member Profile on Website. Link to Professional Register/Certifier Authorisation If you have a link to an external public register you are listed on please copy and paste the link to this here. For Compliance Certifiers this is your listing on the WorkSafe NZ Website. Will be listed in Member Profile on Website. LinkedIn Please copy and paste the link to your LinkedIn Profile here. Will be listed in Member Profile on Website. Business Facebook Page Please copy and paste the link to your Business Facebook Page link here. Will be listed in Member Profile on Website. Insurance InformationThis information will not be listed in Member Profile on the Website.Insurance(Required)Please upload copies of your current professional, public and statutory liability Insurance. Drop files here or Select files Max. file size: 50 MB, Max. files: 5. Qualification/CPD InformationThis information will not be listed in Member Profile on the Website.Qualifications(Required) Health & Safety Inspector appointed under the Heath & Safety at Work Act 2015 HSNO Test Certifier appointed under the HSNO Act 1996 or previous Test Certifier HSNO Enforcement Officer appointed under the HSNO Act 1996 Compliance Certifier appointed under the Health & Safety at Work (Hazardous Substances) Regulations 2017 or previous Compliance Certifier None of the above - please identify below... Details of QualificationsPlease update or add any new qualifications you have received since your last renewal. For Compliance Certifiers this may be extensions to your scope of Authorisation.Certificate(s), Approval(s) or any other Qualification EvidenceUpload any relevant paperwork to confirm your qualifications here. Drop files here or Select files Max. file size: 50 MB, Max. files: 10. Learning Records (CPD)Type of CPDProviding OrganisationHours ClaimedDate of Completion Add RemoveYou can add more rows here as needed. If you have not uploaded your CPD evidence to the CPD Portal then add them here. It is best to upload to the CPD Portal: https://hspnz.certificate.ccert.co.nzCPD Files Drop files here or Select files Max. file size: 10 MB. Upload evidence of your CPD here. Read Our Professional Membership Declaration Show More Text on Click Read Here Professional Members: Shall be individual persons only. Must hold qualifications or Approvals as Hazardous Substances Test Certifiers, Hazardous Substances Compliance Certifiers, or be former Hazardous Substances Test Certifiers or Compliance Certifiers; or May include hazardous substances related Engineers, Consultants, Consultant Landuse Planners, Health and Safety Consultants or Practitioners, or hazardous substances Risk Assessors or Fire Engineers or suitably related professional with experience, knowledge and qualifications to NZQA Level 6 or greater or have equivalent or greater qualifications in their professional discipline. May be eligible on assessment to be listed on the HASANZ Register Shall have successfully completed the membership requirements and has agreed to be bound by these rules, the Code of Conduct and Ethics, and the Society By-Laws as published. Accuracy: The details set out in this Membership Form are true and correct. If they change, I acknowledge that I am required to notify HSP(NZ) Inc. of the changes in writing as soon as possible after they occur. If the details provided are not true or are misleading, I acknowledge my membership may be terminated at the discretion of HSP(NZ) Inc. Bound by Rules: I will be bound by the constitutions, code of ethics, regulations, policies, manuals, guidelines, and reasonable directions of HSP(NZ) Inc. Privacy: I agree that HSP(NZ) Inc can obtain, hold, use, and disclose my personal information as provided on this Form (and any updated or additional personal information HSP(NZ) Inc obtains from me including any photo or other record of my image) for the purposes of: Processing my application for membership, including notifying EPA or WORKSAFE of the information on this form for the purposes of the HSP(NZ) Inc compiling a register of members, compiling a national database of members and participants (accessible only in accordance with the Constitution and Regulations HSP(NZ) Inc), and for requesting me to renew if my membership lapses. Putting my name and contact information on HSP(NZ) Inc membership list for use by other members of HSP(NZ) Inc. Publishing any approved information in HSP(NZ) Inc newsletters and on their websites. Providing me with information and activities relating to HSP(NZ) Inc and other HSNO matters. Including my photograph or other imagery on HSP(NZ) Inc website, in newsletters, annual reports, or similar official publications. Enabling HSP(NZ) Inc. to contact me with information about the products and services of HSP(NZ) Inc. sponsors or funders (unless I have opted out of receiving such information on the Membership Form). Enabling HSP(NZ) Inc to comply with any statute, regulation, by-law or other regulatory instrument that requires collection or disclosure of personal information. Enabling HSP(NZ) Inc to obtain up to date approval information from Worksafe and EPA. Retaining the information provided on this form if my membership lapses (as an inactive member) for a maximum period of three years for the above purposes. Any other purpose I agree to in writing. CPD: I agree as a Professional member of HSP(NZ)Inc. I am required to undertake Continuing Professional Development(CPD) to maintain my membership status. I agree to record and track my annual CPD points. This will ensure that when the annual CPD audit is carried out the correct number of hours that I have participated in throughout the year is registered. I agree and understand that HSP(NZ) Inc can obtain, hold, use, and disclose my personal information as provided on this Form (and any updated or additional personal information Worksafe or EPA obtains relating to my approval status.) for the benefit of obtaining membership support from HSP(NZ) Inc. I acknowledge that I have not been under a professional investigation by an organization for which I am employed or contracted to or a professional body such as Worksafe either in New Zealand or overseas. I have not been expelled or have been denied membership/approval to HSPNZ or any other Professional Organization in the past. Use, Security and Access: I understand that my personal information will only be used for the purposes of HSP(NZ) Inc. My personal information will be held securely. I will have access to my personal information under the Privacy Act. My personal information will be corrected upon request. Enabling HSP(NZ) Inc to obtain up to date approval information from Worksafe and EPA. Continued Membership: I understand that upon payment of my membership fee(s), if I am accepted to membership, I will become a member of HSP(NZ) Inc and that by paying such fee(s) by the due date(s), I will continue to be a member of HSP(NZ) Inc for the duration of my Membership as specified on this form and in accordance with the HSP(NZ) Inc Constitution, unless I resign or my membership is terminated.