(OVERSEAS TRAINED APPLICANTS)

ELECTRICAL W ORKERS
REGISTRATION BO ARD REGISTRATION/REGISTRATION CERTIFICATE/
PRACTISING LICENCE APPLICATION

Please see the back of the form for additional information.

Please print clearly in black or blue pen and complete all required sections of the form.
EW Number

Personal details
Last Name Postal Address
First Name
Middle Name
Date of Birth  /    /   Postcode
Email
Home Phone Work Mobile

What Electrical Class you are applying for (select one)

  Electrical Appliance Serviceperson   Cable Jointer   Electrician   Electrical Service Technician

  Electrical Engineer   Electrical Installer   Line Mechanic

  Electrical Appliance Serviceperson endorsed to disconnect and reconnect

Please specify what you are applying for

  Registration assessment    OR      Registration assessment and registration certificate    OR      Practising licence (completion of registration process)

Training/experience and qualifications

List the training/experience and qualifications you have received in the electrical industry.

Please provide copies of work references and qualifications.

Safety Training
Specify what safety training you have done
(this must be carried out by an Electrical Workers Registration Board approved provider as listed on the Board’s website)
Where (name of training provider) Date completed (Day/Month/Year)
Safe Working Practices  /    /  
Testing  /    /  
First Aid  /    /  
CPR  /    /  

ID Card Photo
Note: All practising licences must display a photo of the licence holder.
The attached photograph is a true and correct likeness of me. It meets all the criteria in the checklist overleaf.

I have already provided my practising licence photo to the Registrar.

Tick this box if you want your photo to be available online to people searching the Register of Electrical Workers.

Fit and Proper Person

All persons who apply for registration or a practising licence must satisfy the Board that they are a fit and proper person. The Board’s rules for administration of
this requirement are published on its website at http://www.ewrb.govt.nz/about-the-board/rules-of-the-board/ or call us on 0800 661 000 for any clarification.
If you think you might not meet the Board’s criteria then please complete this form and submit it. A licensing officer will be in contact to discuss your circumstances.
Note the Board has a discretion to license a person who does not meet the criteria if they are able show that they are a fit and proper person to hold a licence.
Yes I meet the Board’s criteria for fit and proper person to hold a practising licence.

No I may not meet the Board’s criteria for fit and proper person to hold a practising licence. Please get a licensing officer to contact me to discuss my situation.

VER 17/08/15 SAFETY | COMPETENCY | COMPLIANCE 1.4

 Payment of fees
We do not accept purchase orders or cash or postal notes. Consideration can only be given to the issuing of a registration/practising licence following an assessment
of training/experience and qualifications.
The fee payable for registration is $350 (overseas trained). If a registration certificate is required the certificate fee is $57.
The fee payable for a practising licence is dependent on the time of year it is issued. The practising licence fees for each month of the year are shown in the following table:
Month of Month of Month of Month of
Fee Fee Fee Fee
Application Application Application Application
Jul-15 $190.00 Jan-16 $160.00 Jul-16 $130.00 Jan-17 $100.00
Aug-15 $185.00 Feb-16 $155.00 Aug-16 $125.00 Feb-17 $95.00
Sep-15 $180.00 Mar-16 $150.00 Sep-16 $120.00 Mar-17 $90.00
Oct-15 $175.00 Apr-16 $145.00 Oct-16 $115.00 Apr-17 $85.00
Nov-15 $170.00 May-16 $140.00 Nov-16 $110.00 May-17 $80.00
Dec-15 $165.00 Jun-16 $135.00 Dec-16 $105.00 Jun-17 $75.00

Payment for initial application

We do not accept purchase orders or cash or postal notes. The total fee is $350.00. Payment is made by:
  Credit card (Credit card information completed, see below)   NZ Cheque made out to “Electrical Workers Registration Board”

Payment to complete application

Note: Registration requirements must have been met before this payment is made.
We do not accept purchase orders or cash or postal notes. The total fee is
Payment is for: Payment is made by:
  Practicing license   Credit card (Credit card information completed, see below)

  Practicing license and registration certificate   NZ Cheque made out to “Electrical Workers Registration Board”

Credit Card information

Type Full Name of Cardholder
  MasterCard   Visa   Amex

Credit Card number Signature of Cardholder

Expiry Date Amount

/

Please complete the following if your application is being paid for by your employer or another party.
Name / Company name

Address Postcode

Checklist
Have you:
  attached the required fee(s)   attached any required certified copies of certificates/qualifications (please do not submit original documents)
  attached employer work experience reference(s)   completed required safety training.

Declaration

I certifiy that the information

I have provided is true and correct. Signature Date  /    /  

Please return this form with payment to: Electrical Workers Registration Board,
PO Box 10156, Wellington 6143, New Zealand

For more help, call our helpline on 0800 661 000 between 8 am and 5 pm Monday to Friday
or email info@ewrb.govt.nz.

Privacy Notice: Any personal information submitted on this application will be kept and maintained by the Electrical Workers Licensing Group (“the EWLG”) in accordance with the New Zealand
Privacy Act 1993. Personal information submitted will be used by the EWLG for determining whether applications for registration as an electrical worker or practising licences may be granted,
and for the maintenance and administration of the Electrical Workers Register. You may request access to see any information held about you and where that information is inaccurate, ask for it
to be corrected.