PROFESSIONAL MEMBERSHIP Professional Membership Application Name(Required) First Last Gender(Required)MaleFemaleDate Of Birth(Required) MM slash DD slash YYYY Photo IDMax. file size: 128 MB.Email(Required) Phone(Required) Fax (optional) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code TST Approval Number or other Authorisation Number(Required) Industry You Are Working In(Required) Your Current Position(Required) Other Affiliations or Associations You Are A Member OfEmployer or Company InformationCompany Name Name(Required) First Last Email(Required) Phone(Required) Fax (optional) Business Name(Required) Website Numer of Employees(Required) Postal Address(Required) Region(Required)Please select which HSP(NZ) region you are within. Upper North Island Central North Island Lower North Island South Island Insurance(Required)Please upload copies of your professional, public and statutory liability Insurance. Drop files here or Select files Max. file size: 50 MB, Max. files: 5. Qualifications(Required)Please select which Primary Industry Qualifications and/or Relevant Applications you hold 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 under 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)Scope of Authorisation (Compliance Certifier) Drop files here or Select files Max. file size: 20 MB, Max. files: 10. Other Qualification Documents (non Compliance Certifier) Drop files here or Select files Max. file size: 20 MB, Max. files: 10. Learning Records (CPD)Type of CPDProviding OrganisationHours ClaimedDate of Completion Add RemoveCPD Files Drop files here or Select files Max. file size: 10 MB. Have you had any disciplinary action or suspension to your approvals or qualifications that prevent you from working in your current capacity?If so please provide further explanation.Professional ReferencesThese can be other Hazardous Substances professionals, past or present Employers, or even one of your regular customers.First NameLast NameBusiness NameEmailPhone Add Remove Read Our Professional Membership Declaration Show More Text on Click Read Here 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. CDP: 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.
