Complete this form if you want your personal information removed from the SafeWork licence register. You can only request that information be removed from the public register if you believe your personal safety or well-being is impacted due to the information being available.

For further information see the guidelines for changing, removing or suppressing information from the public register. Required fields are marked with an asterisk (*).

Licence/card holder’s name *

Date of birth *

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Licence/card number(s) *

Phone

or email

What information do you want removed from the public register? *

• Name
• Licence type
• Licence number(s)
• Licence class
• Date of issue
• Expiry date
• Details of any surrender, cancellation or suspension of the licence
• The supervisor’s name in relation to an asbestos/demolition licence
• All of the above

Why do you want this information removed? *

Please attach any supporting evidence, such as police reports, court documents, medical evidence or other legal documents.

I declare I am the authorised licence/card holder and the information supplied is true and correct in every particular *

• Yes

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