Location Compliance Certificate
Application Form

LCC Application Form

Contact Details
On-site Particulars
Application Checklist
Declaration

Please do not refresh or navigate away from this page until you have submitted this form as you must do it in one sitting.

You will need the following documents ready before submitting this application:

A copy of the company registration details and bank deposit slip

Other documents strongly recommend but not mandatory to submit:

Evidence of prior Compliance Certification (if applicable)
All email correspondence and notices from WorkSafe / Enforcement Officer
Hazardous Substances Inventory List that is up-to-date for all hazardous substances you have on site
Established training records for all your staff who handle, or are around Hazardous Substances
Records for Certified Handlers and/or Approved Handlers at your site (if applicable)
A HSWA compliant Site Plan for your site
Evidence of security measures for each hazardous substance location for your site
Copies of your Emergency Management Response Plan or ERP Practice documents
Copies of disposal documentation for your site
Documentation on the control of unintended ignition for your site
Records of PPE selection, training, and maintenance to include:
- Medical Assessment (ensuring staff can use respirators,
- Selection of PPE (degradation/accumulation),
- Maintenance + Repair: filter replacement, leaks, holes,
- Compatibility with other PPE, Training: fitting, checking/testing, replacing parts, what to use and when,
- Fitting correct for worker, daily inspection, and separate storage requirements

PCBU / Officer Details

Full Name

Mobile Phone Number

Work Phone Number

Work Email Address

Business Information

Legal Entity/Business Name *

Are you trading under a different name?

Yes

Trading As Name *

Business Email Address

Business Phone Number *

New Zealand Business Number (NZBN)

Go to https://www.nzbn.govt.nz/mynzbn/search/ to find your NZBN.

Description of Business Type

Please select the industry (or nearest equivalent) the business operates in

Business Address

Address Line 1

Text

Address Line 2

Text

City

Text

State/Province

Text

Zip/Postal

Is your postal address the same as above?

Yes

Postal Address *

Postal Address

Address Line 1

Address Line 2

City

State/Province

Zip/Postal

Is this address the same address where LCC is required?

Yes

Please specify the address where LCC is required *

Please specify the address where LCC is required

Address Line 1

Address Line 2

City

State/Province

Zip/Postal

Accounts Information

Name of Company Accounts Point of Contact

First

Last

Accounts Email Address

Mobile Phone Number

Business Fax Number

Work Phone Number

Direct Dial Number

Please upload a copy of the company registration details and a bank deposit slip

Maximum file size: 16.78MB

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Location Compliance Certificate Application Form