Ref. No.		
Individual’s details	
	
Person’s title:		Person’s full name:			
	
Position Title (within the company):			
	
Date of effect of designation:		Mobile Number:			
	
Phone number:		Fax Number:			
	
Email address:			
	
Contact address:			
	
Responsibilities
	
List the sections of the permit for which this individual will carry responsibility for compliance:			

Signature and permit details	
	
Name :			
	
Position:			
	Signature:	_____________________________________	Date:	____/____/________	
	
Permit Holder:		Permit No:			

Explanatory Notes

Ref. No.	 	A sequential reference number is required for each form of this type submitted by the Permit Holder (eg, 001, 002, 003, etc).  Where amendments are made to a previously submitted form, please use the same reference with a sequential revision number (eg, 003-Rev.1).	
Person’s full name		Must include all names, as they appear on your employment records	
Signature		This form must be signed by a representative of the Permit Holder (ie, the organisation) who will take responsibility for, and sign documents on behalf of, the organisation.

		

		

		

		
This form replaces the following forms 	ASO214 (Version 3 issued 5 January 2006)