HSP(NZ) Inc.

Applicant Information

First Name

Last Name

Gender

Date Of Birth

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Email

Phone

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Home Address

Industry You Are Working In

Your Current Position

Other affiliations or associations you are a member of Optional

Employer Information

First Name

Last Name

Email

Phone

Business Name

Website

Number Of Employees

Postal Address

Region

Please select which HSP(NZ) region you are within.

Upper North Island

Central North Island

Lower North Island

South Island

QUALIFICATIONS

Please select which Primary Industry Qualifications and/or Relevant Applications you currently hold or use to have, and then upload copies of certificates or other evidence of approval for each.

Explosives Inspector appointed under the Explosives Act 1957

Dangerous Goods Inspector appointed under the Dangerous Goods Act 1974

Health & Safety Inspector appointed under the Heath & Safety in Employment Act 1992

HSNO Test Certifier appointed unde the HSNO Act 1996

HSNO Enforcement Officer appointed under the HSNO Act 1996

NZ Defence Force Test Certifier appointed under DFO 53

Compliance Certifier appointed under the Health & Safety at Work Regulations 2017

Health & Safety Inspector appointed under the Health & Safety at Work Act 2016

Other Applications or Qualifications you hold (if not listed above)

Certificate or approval PDF or JPEG only

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None of the above

MEMBERSHIP DECLARATION

Please read over the Associate Membership Declaration before submitting your application.

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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 have read and 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:
1. 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; b. Putting my name and contact information on HSP(NZ) Inc membership list for use by other members of HSP(NZ) Inc;
2. Publishing any of approved information in HSP(NZ) Inc newsletters and on their websites;
3. Providing me with information and activities relating to HSP(NZ) Inc and other HSNO/HSWA matters;
4. Including my photograph or other imagery on HSP(NZ) Inc website, in newsletters, annual reports, or similar official publications;
5. 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);
6. Enabling HSP(NZ) Inc to comply with any statute, regulation, by-law or other regulatory instrument that requires collection or disclosure of personal information;
7. 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; and
8. Any other purpose I agree to in writing.
I acknowledge that I have not been under a professional investigation by an organisation 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 Organisation in the past.
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 previous compliance approval status) for the benefit of obtaining membership support or approval from HSP(NZ) Inc.
Use, Security and Access: I understand that my personal information will only be used for the purposes of HSP(NZ) Inc. a. My personal information will be held securely; b. I will have access to my personal information under the Privacy Act; c. My personal information will be corrected upon request. d. 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.

I have read, understood and agree to all rules as per Membership Declaration

I have read, understood and agree to the HSPNZ Code of Ethics