Licensed Electrician · Subcontractor Registration

1

BUSINESS DETAILS

Company Name *

Trading Name (if different)

ABN

Business Structure

Legal Entity Name (as registered with ABN)

2

PRIMARY CONTACT

Full Name *

Position / Title

Mobile *

Email Address *

3

BUSINESS ADDRESS

Street Address

Suburb

State / Postcode

4

ELECTRICAL LICENCE (ESV / VBA)

Electrical Worker Licence No.

Licence Class (A / B / C / D)

Licence Expiry Date

Restricted / Unrestricted

Endorsements (e.g. Instrumentation, Refrigeration, Solar)

Registered Electrical Contractor (REC) No.

Certificate of Electrical Safety (COES) · issue upon job completion? Yes / No

5

Insurance

Public Liability ($5m minimum required)

Public Liability Insurer

Policy Number

Coverage Amount

Expiry Date

WorkCover

Employ workers or apprentices?

WorkCover Insurer

Policy Number

Expiry Date

Required if you employ workers or apprentices.

6

BANKING & PAYMENT

Account Name

BSB

Account Number

Payment Terms

GST Registered? Yes / No

7

NOTES

White Card

White Card No.

Please attach a copy in the Documents section below.

FIRST AID & EMERGENCY

First Aid (HLTAID011)CPR (HLTAID009)Emergency WardenFire Extinguisher

OTHER

Asbestos AwarenessLead Paint AwarenessSWMS PreparationTraffic Management

ADDITIONAL CERTIFICATES · list any not ticked above

Certificate / Qualification

Certificate No.

Issuing Body / RTO

Expiry Date

8

Site Undertakings

I confirm I will provide a trade specific Safe Work Method Statement (SWMS) prior to commencing any High Risk Construction Work on site *

+

Documents

Click to choose files, or drag them here

PDF or image · up to 12 files · 10 MB each

White Card (photo or scan)
Public Liability Certificate of Currency
WorkCover Certificate of Currency (if applicable)
Licence / Registration card
Any High Risk Work licences
Professional Indemnity Certificate of Currency (if applicable)

✓

Declaration

I declare that the information provided in this form is true and correct. I understand that providing false or misleading information may result in immediate termination of engagement with Excell Group. I agree to notify Excell Group immediately of any changes to my licence, insurance, or qualification status.

I have read and agree to the declaration above. *

Full Name (as signature) *

Date *