Terracom Record of Training Experience

This document provides the trainer and assessor with vital information about your current skills and knowledge in the civil and construction industries. Please completed the form honestly, as you will be asked to provide copies of documents as verification of your
skills and knowledge.

Name
Name (If Other) Name (If Other) First Last
Name Name First Last
Current Employer
Please provide a brief description of the tasks undertaken in your current role and provide an example.

EXAMPLE
Civil Safety
Completed machinery operations on various civil construction and mine sites, completed inductions, risk
assessments, VOCs. The machinery I have operated ranges from cranes to heavy earthmoving equipment.
Previous Employment
Please provide a brief description of the tasks undertaken

EXAMPLE
Whilst operating machinery, also acted as a site supervisor, completing JSAs and SOPs, operated all high-risk
equipment as well as site authorised as a dogger, rigger, scaffolder, crane operator, and lifting coordinator.
Please tick the boxes next to the industries you have been employed in.

Please tick the boxes next to the industries you have been employed in. Coal Mining Civil Construction Metalliferous Mining Oil & Gas Warehousing Transport Trade Other Other
I believe that my experience and knowledge in the industry would be considered as:

I believe that my experience and knowledge in the industry would be considered as: New Starter Low level experience Moderate level experience High level experience
Please provide a brief description on how long you have worked in the industry.

EXAMPLE
I have worked in the mining and construction industry for a 30-year period.
Workplace training, I have
completed. Please indicate by
ticking.

Workplace training, I have
completed. Please indicate by
ticking. Site Inductions Safety Training VOCs Toolbox / Prestart Risk Assessment Participation (JSAs, Slams, SWMS) Other Other
I hold the following (please attach evidence), Please indicate by ticking:

I hold the following (please attach evidence), Please indicate by ticking: High Risk Licences (LF, LO, EWP, CN, C2, C6, C100, CO, VN, RB, RI, RA, SB, SI, SA, HP, HM) Drivers Licence (Car, LR, MR, HR, HC, MC, Motor Bike, Boat) RII Competencies (attach or describe) Site Authorisations (copies of LMS) Non-Accredited Training Other Other
Other relevant information:
Please upload training experience documents

Attach Files
By signing this document, I agree that I have provided an honest appraisal of my knowledge and skills to Civil Safety.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / DD / MM YYYY