Reg.

No :

A1 Your Details
Title : CSCS Registration No.
Surname (Family name): (if Renewal or duplicate):
Forename (Given name):
Nationality: Date of Birth:
Work Permit/CIDB Registration:
Employer Company Name: Work Telephone Number:
Site (If known):
Mobile Number:
E-mail Address:

A2 Current Job Title:

A3 Card Type Required Duplicate New Renewal

A4 I am the applicant and I confirm that the details in section A of this form, are to the best of my knowledge, correct and in line
with the Scheme rules (Refer to Card Scheme booklet).

Your Signature: Date :

DD / MM / YYYY

SECTION B(i) For Technical, Supervisory and Mangement Occupations) - please complete this section.

CSCS Occupation Title :

Please tick one box from section 2.

2. Cards
Manager (Black) Professionally Qualified Person (White) Academically Qualified Person (AQP)

Trainee Technical Experienced Technical, Supervisor or Manager Supervisor/Advanced Craft (Gold)

3. Professional & Academic Please provide professional and or academic information

Professional Institution & Membership Grade : Professional Institution Reg. No. :

Academic / Qualification :

NOTE: Evidence of Professional training or acceditation is required to be submitted with the application

SECTION B(ii) For Craft and Operative level occupations - Please complete this section.

CSCS Occupation Title :

Your occupation must be one as listed on the CSCS detailed book as titles vary e.g The CSCS occupation title for a groundworker is a General
Construction Operative (Refer to Card Scheme booklet).
Please tick one box from section below.

Skilled Cards
Industry Accreditation (Blue) Employer apprenticeship Experienced Worker (Red Temporary Card

Other Craft & Operative Cards

Labourer Provisional (Temporary Card) Construction Related Occupation

Escorted Site Visitor Trainee (Craft & Operative)

NOTE: Evidence of qualifications / industry accreditation is to be submitted when applying for Blue Sklled Card
 SECTION C - DECLARATION - Sub contractors must complete this section.

PLEASE ENSURE THIS BOX IS FULLY COMPLETED (The applicant cannot complete this section)

By completing and signing the declaration below, I certify that:

* The applicant meets the requirements for the CSCS card they applying for

* The applicant has been known to me for years.

* The applicant has had at least one year's on-site experience or other experience appropriate to the occupation after initial training (not
applicable for Trainee or Graduates).

Company Name : Signature :

Employer name :
Address :

Postcode : Telephone Number :

CSCS registration Number (if applicable) : Date :

SECTION D ADDITIONAL SKILL LISTINGS

In this section please enter all skills or trade experience that you have gained through formal training or vocational on the job training.
Certificates or other evidence are to be included within the submission.

Skill E.g. Drain layer, carpenter and bricklayer Training Provider

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