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 Requesting Firewood
KAUMATUA DETAILS

Provide the name of the Kaumatua who is requesting firewood.
Kaumatua Name*
Full Name
BE Number *
Kamatua Phone Number *

Permit Holder
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
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
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
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

Clear

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