Registration of Welder Performance Qualification Form 0802

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PRINTED IN B.C.
4500111362
Please refer to our web site or contact a Regional Office to locate the BC Safety Authority office nearest you.
Head Office:
Vancouver Island Regional Office:
Southern Interior Regional Office:
Lower Mainland Regional Office: Northern Interior Regional Office: TOLL FREE NUMBER: 20635 Fraser Highway 3740 Opie Crescent 1.866.566.SAFE (7233) New Westminster: 505 - 6th Street, Suite 200, New Westminster, BC, V3L 0E1 Website: www.safetyauthority.ca Langley, BC V3A 4G4 Prince George, BC V2N 4P7 www.safetyauthority.ca Local Phone: 778-396-2000 fax 778-396-2174 Toll Free: 1-866-566-SAFE (7233) fax 1-888-660-3508
604-927-2041 Coquitlam6th Street, Suite 400 88 250-861-7313 Kelowna Westminster, BC V3L New 250-716-5200 Nanaimo 250-952-4444 Victoria
fax 604-927-2047 Kamloops 3rd Floor, 4243 Glanford Avenue fax 250-861-7349 Langley 5B3 Victoria, BC V8Z 4B9 fax 250-716-5212 Prince George fax 250-952-4458
250-314-6000 Road 250-377-4406 1913 Kent fax 604-539-3573 Kelowna, BC fax 604-539-3570 V1Y 7S6 250-614-9972 fax 250 614 9949
REGISTRATION OF WELDER PERFORMANCE QUALIFICATION
Note: The information on this form is collected to administer the provisions of the BC Safety Standards Act. If you any questions about the collection, use, The information on this form is collected to administer the provisions of the Safety Standards Act. If you have havequestions about the collection, use, or disclosure of this information, contact the Records/FOIPP Coordinator for the BC Safety Authority at telephone at telephone 1-866-566-SAFE (7233). or disclosure of this information, contact the Records, Information & Privacy Analyst for the BC Safety Authority 604-660-6286. The information will be used to process your application for registration of welder performance qualification. This application must be accompanied by a completed A.S.M.E. QW-484 and the required fee, payable to the BC Safety Authority.
A.
Applicant (please print) First name: Street No.: Street Name: Province: Postal Code: Street Type: Telephone: ( ) Birth date:
YYYY MM DD
Welder’s last name: Suite No.: City: Boiler & Pressure Vessel Safety Welder’s Registration no.: Do you have a Welder’s Performance Qualification Record Book? Do you have a welder’s log book? Applicant signature: Yes with “A” seal
Yes
No “B” seal
Welder’s log attached? No Provisional Date:
Yes BCP-100
No
B.
Employer’s (if applicable)
Company name: Suite No.: City: Representative signature: Street No.: Street Name: Province: Postal Code: Street Type: Telephone: ( ) NSEW:
C. Testing Agency (if applicable) Procedure registration no.(s): Testing agency registration no.: T/A Accepted by:
Date test complete: Date:
YYYY MM DD
D.
Safety Officer’s Use Welder’s log book Welder’s Performance Qualification Record Book Safety Officer’s signature: Not entered Date: BCP-100 Cert. issued
YYYY MM DD
Entered in:
Safety Officer’s name:
E. Office: Fee $
Office Use Entry Date: GST $
YYYY MM DD
Technology: Total Fee $
BP
Payment method:
File No.: Date:
YYYY MM DD
Reference: Miscellaneous description:
FRM-0802-01 (2004/10/13) FRM-0802-00 (2009-05-21)
Mail completed form and fee to the BC Safety Authority. White - Head Office Yellow - Audit Pink - Applicant
ORCS 32180-30