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