Occupational Health and Safety (Safety AOccupational Health and Safety (Safety Arrangements) Regulations 1991, regulation 4B

## Occupational Health and Safety (Safety Arrangements) Regulations 1991, regulation 4B Application for issue of certificate All sections must be completed Section 1 For employee representative Name(s) of employee(s): Name, address, contact numbers and e‑mail address of employee representative: Name and address of employer: Name, address, contact numbers and e‑mail address of contact person in employer organisation: Description of proposed consultations: Please provide sufficient detail about the development or variation of the health and safety management arrangements to make it clear which consultations the certificate is to cover. > Note This certificate becomes invalid at the request of the employee(s) covered by the certificate, or after 12 months from the date on which the certificate is issued, whichever occurs first. Section 2 For employees I/we confirm that I/we have asked (name of employee representative), which is entitled to represent me/us, to do so in the consultations described above. I/we wish to remain anonymous during these consultations. I/we confirm that I am/we are current members of (name of organisation/ association). | Signed | Signed | Signed | Signed | Signed | | --------------------- | --------------------- | --------------------- | --------------------- | --------------------- | | signature of employee | signature of employee | signature of employee | signature of employee | signature of employee | > Note If the certificate is to cover more than 5 employees, the signatures must be placed on a separate page and attached to this form. Section 3 For employee representative In compliance with the Occupational Health and Safety Act 1991, (name and address of employee representative) will not reveal the identity of the employee or employees listed above to any other person. (signature for employee representative) Section 4 For employee representative (Name and address of employee representative) applies for the issue of a certificate to the effect that (name of employee representative) is entitled to represent the employee or employees listed in section 1 in the consultations described in section 1. (signature for employee representative) (date) Form 1 Provisional improvement notice (regulation 30)