APPLICATION FOR CERTIFICATE OF QUALIFICATION
LOCAL GOVERNMENT (MISCELLANEOUS PROVISIONS) ACT 1960
Local Government (Qualification of Municipal Officers) Regulations 1984
I, (full name) ________________________________________________________________
of (address) _________________________________________________________________
_____________________________________ Phone: _______________________________
Employer: __________________________________ Phone: _________________________
hereby apply for the issue of a Certificate of Qualification as a Municipal Building
Surveyor under Regulation __________ of the Local Government (Qualification of Municipal
officers) Regulations 1984.
I declare that I was born in ____________________________________________________
on _______________________________ 20____.
(a) Copies of relevant academic qualifications
(b) Evidence of membership of relevant organisations
(c) Statement of work experience to include:
− names of employers;
− periods of employment; and
− details of positions held, including a detailed statement of the duties and responsibilities
of each position.
(To be presented in typed format on A4 paper)
(d) A cheque for $20 (to cover fees prescribed) made out to the Department of Housing and
Works, 108 Adelaide Terrace, EAST PERTH 6004, Attention Antony Mee.
Signature __________________________ Witness ____________________________
Date _____________________________ Date ______________________________