SURFACE SHOTFIRING RPL APPLICATION RPL APPLICATION FORM SURFACE SHOTFIRING This form asks you to provide information about yourself and your request for Recognition of Prior Learning. The information given in this application form will enable your past education and experience to be measured against outcomes of the relevant units of competency. Units of competency I wish to obtain RPL for: Unit/Course Code Unit//Course Name RIIBLA205D Store, handle and transport explosives RIIBLA301D Conduct surface shotfiring RIIBLA305D Conduct secondary blasting Applicant Details: 1 Personal Details Date: USI number Preferred Title Mr, Mrs, Ms, Miss Surname Former surname Name/s Preferred name Street Address Suburb Postcode Postal address if different from above Telephone Numbers Date of Birth Gender Home: Work: Mobile: Fax: / □ □ / Age Male Female E-mail address Emergency contact Name: Relationship Home Phone Mobile Town/ city of birth Country of birth Version 1.0 Document Surface Shotfiring RPL Application Revision Dates Feb 2015 Document Number TP-07-09 This document is uncontrolled in hard copy format Page 1 of 8 SURFACE SHOTFIRING RPL APPLICATION Are you a permanent resident of Australia Do you speak a language other than English at home? Do you mainly speak English at home? Proficiency in spoken English □ No □ Yes □ No English only □ Yes, other, please specify _ □ No □ Yes Very well Well Not well Not at all Are you of Aboriginal or Torres Strait islander origin? No Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal and Torres Strait Islander Do you consider yourself to have a disability, impairment or long term condition? No Yes If YES, please indicate the areas of disability Impairment or long term condition. Hearing/ deaf Physical Intellectual Learning Mental illness Acquired brain impairment Vision medical condition other, please specify (you may indicate more than one area) Are you still in school? No Yes attending secondary school Where did you complete your schooling? What is your highest completed school year? Did not go to school Year 8 or below Year 9 or equivalent Completed year 10 Completed year 11 Completed year 12 In which year did you complete that school level? Version 1.0 Document Surface Shotfiring RPL Application Revision Dates Feb 2015 Document Number TP-07-09 This document is uncontrolled in hard copy format Page 2 of 8 SURFACE SHOTFIRING RPL APPLICATION Have you successfully completed any of the following qualifications? No Yes If YES tick any applicable boxes Advanced Diploma or Associate Degree Bachelor Degree or higher Certificate I Certificate II Certificate III Certificate IV Diploma (or Associate Diploma) Miscellaneous education/ certificates other than the above Of the following categories, which best describes Employed – Unpaid worker in a family business Employer your current employment status? Full-Time employee Not employed – not seeking employment (one box only) Part-Time employee Self Employed - not employing others Unemployed – seeking full-time work Unemployed – seeking part-time work What is your main reason for undertaking this course/traineeship/apprenticeship (tick one box only) To get a job To develop my existing business To start my own business To try for a different career To get a better job or promotion It was a requirement of my job I wanted extra skills for my job To get into another course of study For personal interest or self-development Other reasons 2 Current Employment If you are currently employed, in which occupation are you currently employed? ……………………………………………………… Who is your current employer? ………………………………………………………. Trade classification on discharge 3. Further Training YES □ / NO □ Have you undertaken any training courses related to the occupation applied for? If Yes What occupation were you trained in? Training completion Date (month, year) Country where you trained Name of course and institution (if applicable) 4. Is there any further information you wish to give in support of your application Version 1.0 Document Surface Shotfiring RPL Application Revision Dates Feb 2015 Document Number TP-07-09 This document is uncontrolled in hard copy format Page 3 of 8 SURFACE SHOTFIRING RPL APPLICATION 5. Professional Referees (relevant to work situation) 1. Name …………………………………………………………………… Position …………………………………………………………………… Organisation …………………………………………………………………… Phone Number …………………………………………………………………… Mobile Number …………………………………………………………………… Email Address …………………………………………………………………… 5. Professional Referees (relevant to work situation) 2. Name …………………………………………………………………… Position …………………………………………………………………… Organisation …………………………………………………………………… Phone Number …………………………………………………………………… Mobile Number …………………………………………………………………… Email Address …………………………………………………………………… 5. Professional Referees (relevant to work situation) 3. Name …………………………………………………………………… Position …………………………………………………………………… Organisation …………………………………………………………………… Phone Number …………………………………………………………………… Mobile Number …………………………………………………………………… Email Address …………………………………………………………………… Version 1.0 Document Surface Shotfiring RPL Application Revision Dates Feb 2015 Document Number TP-07-09 This document is uncontrolled in hard copy format Page 4 of 8 SURFACE SHOTFIRING RPL APPLICATION EMPLOYMENT HISTORY FORM Name, Address and Phone number of Employers Period of Employment Position Held Full Time Description of Major Duties Part-time (DD/MM/YYYY) Casual From /To 1. 2. 3. 4. Attach additional sheet if required If you are including documents in your application, please provide a brief description below Office Use Only – Assessor to use this section to align documents to specific units of competency and identify key questions for competency conversation Document Description (e.g. resume, photos, awards etc) Version 1.0 Document Surface Shotfiring RPL Application Revision Dates Feb 2014 Document Number TP-07-09 This document is uncontrolled in hard copy format Page 5 of 8 SURFACE SHOTFIRING RPL APPLICATION STUDENT DECLARATION Declaration I declare that the information contained in this application is true and correct and that all documents are genuine. I believe that I am eligible for recognition of current competency on the following grounds: I agree to pay the fees involved and any fees per assessment for any challenge test that is required for me to confirm my competency. I understand that travel and accommodation for an assessor to conduct on site assessments will be added to any assessment fees quoted. I understand that the RPL process is an assessment only process whereby I submit evidence. Modular training will count any competency achievement towards any grading in future competency based summative assessments. I understand that there is no training or learning guide provided to me in this process and that I am using this process to fast track my certification. I understand that Modular Training is not responsible for searching, or discovering any information or supporting evidence. I understand that I am responsible to supply all supporting evidence and information required by Modular Training, and I shall pay any additional search and discovery fees incurred as a result of insufficient evidence being provided. I understand that I shall not be entitled to any refund of fees in the event that I do not meet the competency standards and that any further training and assessments I require shall be at my expense at the current Modular Training rate. I, _______________________ have read the RPL Policy and understand that if this application is successful that a RPL pack will be provided to me for the relevant units of competency, at a briefing session. I understand that I will only receive RPL for those modules upon successful submission of all requirements as outlined in the RPL Pack for each module. Student Signature :_______________________________ Date: / / *Please Note: the Assessor may contact your referees to confirm details of your skills and experience. Version 1.0 Document Surface Shotfiring RPL Application Revision Dates Feb 2015 Document Number TP-07-09 This document is uncontrolled in hard copy format Page 6 of 8 SURFACE SHOTFIRING RPL APPLICATION Student to complete for a self-evaluation of knowledge of Surface Shotfiring units to qualify for the RPL process and to ascertain if any gap training required: 1. Do you hold a current Dangerous Goods Security Card and a Shotfiring Licence? document licence numbers and expiry dates. If so please DGSC number:___________________________________________________________________ DGSC expiry:____________________________________________________________________ Shotfiring licence number:___________________________________________________________ Shotfiring licence expiry:____________________________________________________________ 2. Do you or have you charged blast holes in a surface site? If yes list site name and dates. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 3. Have you been responsible for or involved in tie-in and firing of a shot on a surface site? site name and dates. If yes list ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 4. Do you or have you transported explosives? YES 5. NO What signage is required for the explosive vehicle? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 6. Are you responsible for or involved in the handling and storage of explosives on site? YES 7. NO What regulations and standards do you need to comply with when transporting, storing, handling and using explosives? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Version 1.0 Document Surface Shotfiring RPL Application Revision Dates Feb 2015 Document Number TP-07-09 This document is uncontrolled in hard copy format Page 7 of 8 SURFACE SHOTFIRING RPL APPLICATION 8. Have you performed secondary blasting? (e.g. oversize, toe, flare, refiring misfires) YES 9. / NO What is the difference between secondary and a production blast? ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________ To be filled out by RTO assessor Does the student qualify for the RPL process Yes No If the student can answer the questions above accurately continue with the RPL, if unable to complete, discuss options with the assessor for full or gap training. Version 1.0 Document Surface Shotfiring RPL Application Revision Dates Feb 2015 Document Number TP-07-09 This document is uncontrolled in hard copy format Page 8 of 8