ACCREDITATION APPLICATION FORM
To be completed only after having read the Accreditation Scheme Rules, Protocols and Guidelines
INSTRUCTIONS:
To use this form, please print a copy, complete the form and sign the declaration, then post to the Scheme Assessor, Mr Ray Bennett, 1 Wynnland Gardens, Carnmoney, Newtonabbey, Northern Ireland BT36 6SD
SECTION ONE – DETAILS OF THE SRO
Name __________________________________________________________
Address (for correspondence)
_______________________________________________________________
_______________________________________________________________
Main Telephone Number _________________________________
Contact Person _________________________________________
E-mail ________________________________________________
Subsidiaries or associated companies__________________________________
________________________________________________________________
SECTION TWO – LOCATIONS TO BE COVERED
Main Base Address
Telephone No. for oil spill call-out
Accreditation Levels sought for Main Base: (please insert ticks to indicate appropriate disciplines and levels)
DISCIPLINE LEVEL 1 LEVEL 2 LEVEL 3
Freshwater (FW)
Groundwater (GW)
On-land (OL)
Marine (M)
Shore line (SL)
Tanker Rollover (TRO)
Note that Level 3 is the only option available for TRO accreditation
Additional Base 1. Address
Telephone No: for oil spill call-out
Accreditation Levels sought for Additional Base 1: (please insert ticks to indicate appropriate disciplines and levels)
DISCIPLINE LEVEL 1 LEVEL 2 LEVEL 3
Freshwater (FW)
Groundwater (GW)
On-land (OL)
Marine (M)
Shore line (SL)
Tanker Rollover (TRO)
Note that Level 3 is the only option available for TRO accreditation
Additional Base 2. Address
Telephone No. for oil spill call-out
Additional Base 3. Address
Telephone No. for oil spill call-out
Accreditation Levels sought for Additional Base 2: (please insert ticks to indicate appropriate disciplines and levels)
DISCIPLINE LEVEL 1 LEVEL 2 LEVEL 3
Freshwater (FW)
Groundwater (GW)
On-land (OL)
Marine (M)
Shore line (SL)
Tanker Rollover (TRO)
Note that Level 3 is the only option available for TRO accreditation
Additional Base 3. Address
Telephone No. for oil spill call-out
Accreditation Levels sought for Additional Base 3: (please insert ticks to indicate appropriate disciplines and levels)
DISCIPLINE LEVEL 1 LEVEL 2 LEVEL 3
Freshwater (FW)
Groundwater (GW)
On-land (OL)
Marine (M)
Shore line (SL)
Tanker Rollover (TRO)
Note that Level 3 is the only option available for TRO accreditation
OFFENCES
Has the SRO been convicted of an environmental offence, including waste management offences, or is a prosecution pending in relation to spill response activities in controlled water?_____________________________________________
If so, please give date(s) and circumstances _______________________________
_____________________________________________________________________
_____________________________________________________________________
NB. Failure to provide accurate information will invalidate the application. Anyone convicted of an environmental offence, or who has a prosecution pending, specifically connected with oil spill clean-up activities, within the last three years will not be considered for accreditation.
SECTION THREE – DECLARATION BY SIGNATORY
In signing this document, I hereby declare that to the best of my knowledge and belief the statements given in this application, together with the supporting schedules, are correct and true and that I accept the disciplines imposed by the Scheme.
Questionnaire completed by
Name _________________________________________________________
Position in SRO _____________________________________________
Signed ___________________On behalf of:_____________________________
Date ___________________________________________________________
One copy of this document to be retained by the SRO, one copy to be retained by the Scheme Assessor.
(V.5 Last revised July 2010)
