Clone of Permit Kaumatua Application to Collect Firewood

PERMIT APPLICATION

TO COLLECT FIREWOOD
Omataroa Rangitaiki 2 Trust has multi-hazard working sites; therefore, anyone wishing to access these sites, must obtain and carry a valid permit and abide by the CONDITIONS OF ISSUE.

The Trust has LIMITED STOCKS of firewood avaiable to collect by Kaumatua aged 60+.

Applications will be considered and if successful a permit will be issued and sent to the email address provided.
- KAUMATUA DETAILS
  
  Provide the name of the Kaumatua who is requesting firewood.
- Kaumatua Name*
  Full Name
- BE Number *
- Kamatua Phone Number *
- PERSON DRIVING THE VEHICLE
  
  Person who applies for the firewood permit is the driver of the vehicle entering the working site.
- Vehicle Driver Information *
  
  First NameLast Name
- Phone *
- E-mail*
  example@example.com
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- DRIVERS LICENCE
  
  The driver must have a full driver licence appropriate for your vehicle type. The driver must carry his/her drivers licence and avaiable to be viewed on request.
- Licence Numner *
- Expiry Date *
- Class *
- Are there passengers in the vehicle with you?*
  
  YesNo
- Do you have any exisiting Medical Conditions or Allegeries?*
  
  YesNo
- Specify Medical Condition or Allergies (if applicable)
- VEHICLE INFORMATION
  
  Vehicles must meet Ministry of Transport standards for Vehicle Registration, Warrant of Fitness (W.O.F) or Certificate of Fitness (C.O.F)
- Make of Vehicle
- Colour of Vehicle
- Registration Number
- Warrent of Fitness Expiry Date
- Vehicle Registration Expiry Date
- PASSENGER INFORMATION
  
  If there are passengers in your vehicle, the full names are required on the application form. Entry is not permitted to persons under the age of 13 years.
- EMERGENCY CONTACT INFORMATION
- BOOK AN APPOINTMENT
  
  Book an appointment to collect your firewood
- PERMIT CONDITIONS
- Obtaining a permit you can be directed away from hazardous areas and putting yourself at risk.
  - The permit is valid for the date and time specified on the licence.
  - The permit is not transferable to other persons or vehicles. It applies only to the person(s) and the vehicle(s) named on the permit. It must be always carried and be produced on demand.
  - The permit holder must carry their drivers’ licence, mobile phone along with their Access Permit.
  - This permit grants you access to Kiwifruit Orchard located at 133 MacDonald Road for the purpose of firewood gathering.
  - Keep within the perimeter noted on your access permit.
  - Person carry a firewood permit will be always escorted unless you are appropriately trained, qualified competent and authorised to move about the site independently.
  - Excercise caution when operating a vehicle on the property.
  - Take caution on slippery tracks and lanes while driving and walking.
  - Permit Holder is responsible for the passengers recorded on this permit.
  - Report all incidents, near misses and hazards.
  - No smoking or vaping is permitted.
  - In event of an emergency, follow all instructions given.
  - If you observe any unsafe or suspicious activity contact Prudence Elliott 027 9295693, then Maurice 021 09122322.
  - Always follow instructions of Omataroa Rangitaiki 2 staff
  - All visitors must comply with Health & Safety at Work Act 2015 and other revelant acts, regulations and approved codes of practice.
- I have read and understand the conditions of this permit*
  
  YesNo
- Signature

- Upload Signed Induction Form
  
  Browse Files
  
  Cancelof

- Vehicles shall only enter the site along the accessways directed and identified below. Heavy vehicles, including vehicles carry firewood must exit the site via Paul Road.
- Site Front Entry
  
  133 MacDonald Road
  
  RD 2 Whakatane.
- Firewood Site
  
  Firewood site next to Round Shed.
- Site Exit
  
  Loaded vehicles must exit via
  Paul Road.Follow the road past
  
  The Round Shed.
- You are entering a multiple hazard area.
  
  Persons entering this property must comply with Health and Safety Act 2015 and other revelant acts, regulations and approved codes of practice.
- Please register upon entry and exit of the property.
- Report accidents or near misses while on the property.
- Protective Clothing identifed below must be worn
  
  always when on site accessing firewood.
  - Covered shoes
  - Hi-VIZ (supplied by the Trust)
- Take caution on slippery tracks and lanes while driving and walking.
- Exercise caution when operating a vehicle on the property.
  
  Helmets are required when driving a quad or motorbike.
- Smoking or vaping is not permitted.
- No entry is permitted for persons under the age of 13 years.
- Take extreme care around buildings with
  
  hazardous materials including chemicals.
- Emergency assembly site at located near the
  
  round implement shed.
- Emergency assembly site at located near the
  
  round implement shed.
- Emergency assembly site at located near the
  
  round implement shed.
- In case of a serious emergency, dial 111
- Should be Empty:

PERMIT APPLICATION

KAUMATUA DETAILS

PERSON DRIVING THE VEHICLE

DRIVERS LICENCE

VEHICLE INFORMATION

PASSENGER INFORMATION

EMERGENCY CONTACT INFORMATION

BOOK AN APPOINTMENT

PERMIT CONDITIONS

You are entering a multiple hazard area.

In case of a serious emergency, dial 111