CTHRepealedLegislation
Safety, Rehabilitation and Compensation Act 1988 - section 34S - Approval of Form of Application for Renewal of Approval as a Rehabilitation Program Provider (Workplace Rehabilitation Provider) (30/10/2009)
Part A— Applicant Details
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Turn the raw legal text into a practical explanation grounded in Safety, Rehabilitation and Compensation Act 1988 - section 34S - Approval of Form of Application for Renewal of Approval as a Rehabilitation Program Provider (Workplace Rehabilitation Provider) (30/10/2009).
Part A – Applicant Details
Name of the workers’ compensation authority where this application is being submitted to:
______________________________________________________________________
| Business Name | |
|---|---|
| 2. ABN and origin(to determine location of ‘home’ jurisdiction) | Attach copy of the ABN record from the Australian Business Registry. |
| 3. Organisation | Indicate the nature of your organisation (i.e. company, partnership, sole trader, individual subsidiary of a Government body)Full name of your organisation including trading nameACNName and address of any parent organisation, if applicable.Name and position of person/s authorised to sign this application on behalf of the organisation. |
| 4. Provider/site approval numbers | List the number(s) issued by the workers’ compensation authority. |
| 5. Addresses | Organisation AddressPostal Address |
| 6. Phone Number | |
| 7. Fax | |
| 8. Email | |
| 9. Contact person for this application | NameTitlePhoneEmail |
<table cellspacing="0" cellpadding="0" style="width:488.1pt; border:0.75pt solid #000000; border-collapse:collapse"><tbody><tr><td style="width:125.35pt; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding:5.03pt; vertical-align:top"><p style="margin-left:28.35pt; text-indent:-21.25pt; font-size:11pt"><span style="font-weight:bold"><span>10.</span></span><span style="font:7pt 'Times New Roman'"> </span><span style="font-weight:bold">Name of person/s who meet the organisational management structure requirements as outlined in Section 2.2, Principle Two: Organisational & administrative arrangements in particular sub-principle 2.5 of this form.</span></p></td><td colspan="2" style="width:340.4pt; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding:5.03pt; vertical-align:top"><p style="font-size:11pt"><span style="font-style:italic">Name/s</span></p><p style="font-size:11pt"><span></span></p><p style="font-size:11pt"><span style="font-style:italic"></span></p><p style="font-size:11pt"><span style="font-style:italic">Titles</span></p><p style="font-size:11pt"><span></span></p><p style="font-size:11pt"><span style="font-style:italic"></span></p><p style="font-size:11pt"><span style="font-style:italic">Qualifications and workplace rehabilitation experience of the person/s meeting this requirement</span></p><p style="font-size:11pt"><span style="font-style:italic"></span></p><p style="font-size:11pt"><span style="font-style:italic">Phone</span></p><p style="font-size:11pt"><span></span></p><p style="font-size:11pt"><span style="font-style:italic"></span></p><p style="font-size:11pt"><span style="font-style:italic">Email</span></p><p style="font-size:11pt"><span></span></p><p style="font-size:11pt"><span></span></p></td></tr><tr><td style="width:125.35pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding:5.03pt; vertical-align:top"><p style="margin-left:28.35pt; text-indent:-21.25pt; font-size:11pt"><span style="font-weight:bold"><span>11.</span></span><span style="font:7pt 'Times New Roman'"> </span><span style="font-weight:bold">Other workers compensation authorities where approval has been granted.</span></p></td><td colspan="2" style="width:340.4pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding:5.03pt; vertical-align:top"><p style="font-size:11pt"><span></span></p><p style="font-size:11pt"><span style="font-style:italic">List the jurisdictions in which the applicant has a current Instrument of Approval.</span></p></td></tr><tr style="height:37.9pt"><td rowspan="2" style="width:125.35pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding:5.03pt; vertical-align:top"><p style="margin-left:28.35pt; text-indent:-21.25pt; font-size:11pt"><span style="font-weight:bold"><span>12.</span></span><span style="font:7pt 'Times New Roman'"> </span><span style="font-weight:bold">Referees</span></p></td><td colspan="2" style="width:340.4pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding:5.03pt; vertical-align:top"><p style="font-size:11pt"><span style="font-style:italic">Provide the contact details of two referees who can attest to your organisation’s suitability as a workplace rehabilitation provider organisation including statements as to the professional integrity, honesty and due diligence of your organisation’s owner/s and/or management.</span></p></td></tr><tr style="height:37.85pt"><td style="width:164.8pt; border:0.75pt solid #000000; padding:5.03pt; vertical-align:top"><p style="font-size:11pt"><span></span></p><p style="font-size:11pt"><span style="font-style:italic"></span></p></td><td style="width:164.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:11pt"><span></span></p><p style="font-size:11pt"><span style="font-style:italic"></span></p></td></tr><tr><td style="width:125.35pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding:5.03pt; vertical-align:top"><p style="margin-left:28.35pt; text-indent:-21.25pt; font-size:11pt"><span style="font-weight:bold"><span>13.</span></span><span style="font:7pt 'Times New Roman'"> </span><span style="font-weight:bold">Previous Applications</span></p></td><td colspan="2" style="width:340.4pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding:5.03pt; vertical-align:top"><p style="font-size:11pt"><span style="font-style:italic">Has your organisation, any of its owner/s and/or management and/or any persons employed or engaged to deliver workplace rehabilitation services by your organisation been refused approval as a provider of rehabilitation services or had approval been withdrawn as a provider of rehabilitation services in any Australian workers’ compensation jurisdictions?</span></p><p style="font-size:11pt"><span style="width:36pt; display:inline-block"></span><span style="width:36pt; display:inline-block"></span><span>Yes / No</span></p><p style="font-size:11pt"><span style="font-style:italic"></span></p><p style="font-size:11pt"><span style="font-style:italic">If so, provide details of the circumstances and reasons why there is no cause to reject your organisation’s application.</span><span style="font-style:italic"> </span><span style="font-style:italic">These details should state whether the refused approval was associated with:</span></p><ol style="margin:0pt; padding-left:0pt; list-style-type:lower-latin"><li style="margin-left:67.25pt; padding-left:4.75pt; font-size:11pt; font-style:italic"><span>Your organisation, or</span></li><li style="margin-left:67.25pt; padding-left:4.75pt; font-size:11pt; font-style:italic"><span>Any of its owner/s, or</span></li><li style="margin-left:66.63pt; padding-left:5.37pt; font-size:11pt; font-style:italic"><span>Any of its management, or</span></li><li style="margin-left:67.25pt; padding-left:4.75pt; font-size:11pt; font-style:italic"><span>Any of its employees including contractors and staff.</span></li></ol><p style="font-size:11pt"><span></span></p><p style="font-size:11pt"><span></span></p></td></tr></tbody></table>