Please read the accompanying guidance notes before completing this form Please tick as necessary: INITIAL APPLICATION candidate has never been on the register before Please fill in sections 1, 2, 4, 5, and 6 ADDITIONAL QUALIFICATION candidate has a valid SWQR card, and has taken extra qualifications Please fill in sections 1 to 6 REPLACEMENT CARD candidate is on the register and card is valid, but has been lost or stolen Please fill in sections 1, 3, 4, and 6 RE-REGISTER CARD Scotland/ Wales/ Northern Ireland ONLY; candidate’s card has expired and must be re-registered Please fill in sections 1, 3, 4, and 6 RE-ASSESSED CARD England ONLY; candidate’s card has expired in the last six months and candidate has passed re-assessment Please fill in sections 1 to 6 Certificates MUST be attached RETAKEN QUALIFICATIONS candidate’s card has expired more than six months ago and the candidate has re-sat full qualifications Please fill in sections 1 to 6 1: CANDIDATE DETAILS – Please complete in full PHOTO Please use glue only TITLE (Mr/ Mrs/ Miss/ Ms) FORENAMES(S) SURNAME DATE OF BIRTH (Enter DDMMYYYY) DATE STAMP CARD TYPE 2: AWARDING BODY REGISTRATION NUMBER (Required): 3: EXISTING SWQR REGISTRATION NUMBER: Tick here if card lost/ stolen 4: ADDRESS WHICH CARD IS TO BE SENT TO: ADDRESS TO LINE 1 LINE 2 TOWN POSTCODE CONTACT PHONE NUMBER MAIL CHECK LIST – For office use ONLY SWQR EXPIRY DATE DATA CHECKED PO CHECKED REASS QUALS CHCKD
5: QUALIFICATIONS COMPLETED PLEASE TICK FOR INITIAL/ ADDITIONAL QUALIFICATIONS, PLEASE USE ‘R’ FOR REASSESSMENTS √ QUAL TITLE UNITS RE-ASSESS UNITS O1 EXCAVATION IN THE ROAD/ HIGHWAY 001/ 002/ 003 101/ 102/ 103 O2 EXCAVATION, BACKFILLING AND RE-INSTATEMENT – COLD LAY 001-006 101-106 O3 REINSTATEMENT HOT& COLD LAY BITUMINOUS MATERIALS 001/ 002/ 006/ 007 101/ 102/ 106/ 107 O4 REINSTATEMENT OF CONCRETE SLABS 001/ 002/ 008 101/ 102/ 108 O5 REINSTATEMENT MODULAR SURFACES & CONCRETE FOOTWAYS 001/ 002/ 009 101/ 102/ 109 O6 SIGNING, LIGHTING, & GUARDING 002 102 S1 MONITOR EXCAVATION IN THE ROAD/ HIGHWAY 001/ 010/ 011 101/ 110/ 111 S2 MONITOR EXCAVATE, BACKFILL AND RE-INSTATE – CONSTRUCT LAYERS 001/ 010-014 101/ 110-114 S3 MONITOR REINSTATE HOT & COLD LAY BITUMINOUS MATERIALS 001/ 010/ 014 101/ 110/ 114 S4 MONITOR REINSTATEMENT OF CONCRETE SLABS 001/ 010/ 015 101/ 110/ 115 S5 MONITOR REINSTATE MODULAR SURFACES & CONCRETE FOOTWAYS 001/ 010/ 016 101/ 110/ 116 S6 MONITOR SIGNING, LIGHTING & GUARDING 010 110 Specify Country of Work ENGLAND SCOTLAND WALES NORTHERN IRELAND 6: FEES AND PAYMENT (valid until 31 March 2015) CHEQUE/ POSTAL ORDER Please make out to ‘SWQR’ INITIAL REGISTRATION £25.10 ADDITIONAL QUALIFICATIONS £20.15 REPLACEMENT CARD £20.15 RE-REGISTRATION (within three months of expiry) £20.15 RE-REGISTRATION (outside three months of expiry) £25.10 REASSESSED CARD £25.10 CENTRE NUMBER PLEASE LIST CENTRE NUMBER: Only SWQR approved centres are invoiced for payment PURCHASE ORDER NUMBER: As required by centre I the undersigned hereby certify that the above candidate details have been completed accurately. Please note that all information given will be taken as precise by SWQR and no liability will be held for inaccurate information SIGNATURE DATE PRINT NAME RETURN TO: SWQR, THE OPTIMA BUILDING, 58 ROBERTSON STREET, GLASGOW, G2 8DQ TEL: 0345 270 2720 FAX: 0345 213 5000 WEBSITE: www.swqr.org.uk