Permit to Work Authorisation Form Please enable JavaScript in your browser to complete this form. - Step 1 of 4This permit is only valid for the day of issue, on every occasion that additional work is carried out a new permit is to be issued. Contractor Company:Contractor Contact: Location Of The Work: Work Start Date / Time:DateTimeWork Completion Date / Time:DateTimeScope of work to be completed:Representative responsible for supervising contractor:NextTasks to be performed include, or could include: Tasks To Be Completed Hot work (including welding, cutting and grinding etc)Work in high traffic areasWork on Fire Alarm SystemEvacuation or TrenchingWork likely to disturb asbestosWork likely to produce dust or fumesUse of Mobile Plant (eg. forklift, crane)Work likely to produce dust or fumesConfined space entryUse of Pneumatic toolingUse of Hazardous chemicals (Paints, Fuels, Solvents, etc)Other - Please state belowOther Task (Specify): NextContractors Declaration:Have you provided a Specific Safe Work Method Statement (or other safe work procedure eg: Job Safety Analysis) for the work to be performed, which details controls measures for the hazards listed above?YesNoThe above location has been thoroughly inspected and safety precautions carried out?YesNoWhere applicable, automatic fire alarms and detection systems/zones have been isolated?YesNoHave you ensured adequate segregation of works from staff, visitors or members of the public?YesNoAre you competent to safely complete these works?YesNoAdditional Restrictions / Control Measures: NextAuthorisationsSignature of Contractor Responsible for the work: Clear Signature Print Name *FirstLastContractor Responsible - Email *Signature of Person Authorising the work: Clear Signature Name *FirstLastEmail - Authorising Person *Submit