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4. Declaration by Referee

I -holder of Qualified Supervisor Certificate/Contractor Licence (Q) No.

declare that:

• I understand that the provision of false or misleading information by me may result in proceedings being brought against me under the Crimes Act
1900 that could lead to imprisonment of to ten years and/or fines of up to $22,000.

• I have read and understand the information provided in section 5 “The purpose of an Electrical Work Contractor Licence or
Qualified Supervisor Certificate” of this form.

• I certify that the applicant was employed/supervised by me between the following dates / / to / /
during which time s/he held the position of and that s/he carried out the following electrical work at my supervision

Please provide a detailed description of the electrical wiring installation work performed and the time spent on
each aspect of the electrical trade in accordance with AS/NZS 3000:2000, in commercial, industrial &/or domestic
situations, including a period of low voltage work.
Example: installation of consumer mains, rewiring domestic dwelling, general light and power installation.
Please note: Electrical wiring work means the actual physical work of installing, repairing, altering, removing or adding
to an electrical installation and the supervising of the work.

I authorise the Office of Fair Trading to make the necessary enquiries with any organisation or individual to verify the information I have provided
on this form and any organisation or individual to disclose relevant information to the Office of Fair Trading for these purposes

Signature of Licensee (Q)/Qualified Supervisor Date Signed

5. The Purpose of an Electrical Work Contractor Licence or Qualified Supervisor Certificate

An Electrical Work Licence or Qualified Supervisor Certificate is granted to persons who have proven ability to do electrical installations of fixed
appliances, wires, fitting or apparatus or other electrical equipment placed in, on, under or over any land or premises.
REFEREE’S STATEMENT ELECTRICAL WORK 07/11/2006