New Supplier Form

New Supplier Form

CF-019-03 New Supplier Form
Company name:*
Full name of primary contact:*
Email of primary contact:*
example@example.com
Mobile Number:*
Office Number:

Area CodePhone Number
Years in business:*

0 to 2 Years3 to 5 Years6 + Years
Services offered: *
Office or warehouse address:*
Physical address is required. PO Boxes will not be accepted.
Email for remittances:*
example@example.com
Upload Public Liability Insurance Certificate of Currency:*

Cancelof
Workers' Compensation Insurance
This company has employees and I have a workers insurance policy.I am a sole trader and I have a personal accident or income protection policy.I do not have an applicable workers insurance policy
We cannot proceed with your application as it lacks the necessary workers' insurance coverage.
Upload Certificate of Currency of policy.*

Cancelof
Professional Indemnity Insurance

(Required if undertaking design work)
Upload Certificate of Currency

Cancelof
ABN:*
Are you registered for GST?*

YESNo
Account name:*
BSB:*
Account number:*
Incident & Safety Information
Safety incidents in last 3 years?*

0 Incidents1-2 Incidents3-4 Incidents5+ Incidents
Please explain in detail these incidents, including the dates of the incidents.
Environmental incidents in last 3 years?*

0 Incidents1-2 Incidents3-4 Incidents5+ Incidents
Please explain in detail these incidents, including the dates of the incidents.
Lost Time Injuries in last 3 years?*

0 Injuries1-2 Injuries3-4 Injuries5+ Injuries
Please explain in detail these injuries, including the dates of the injuries.
Medical Treatment Injury in last 3 years?*

0 Injuries1-2 Injuries3-4 Injuries5+ Injuries
Please explain in detail these injuries, including the dates of the injuries.
Fatalities in last 3 years?*

0 Fatalities1+ Fatalities
Please explain in detail these fatalities, including the dates of the fatalities.
Do you use subcontractors?*

YesNo
Do you have a full-time Safety Manager?*

YesNo
Do you have a documented Safety Management System?*

YesNo
Copy of Safety Management System*

Cancelof
Scope of Services
Do you employ or engage anyone else (other than yourself) to carry out the subcontracted work?*

YesNo
Do you provide the same or similar services to other clients?*

YesNo
Do you supply any goods or materials as part of your subcontractor services?*

YesNo
Are you being engaged for a specific project?*

YesNo
I confirm that I am an authorised representative of the business and that all information provided is accurate, truthful, and supported by reasonable evidence. I understand that providing false or misleading information is a serious breach of legal obligations and may result in penalties.*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date
Calculation
Low Risk Score Range: 25–32 points
Description: Safety performance and systems are considered adequate. Standard contract conditions apply.
Medium Risk Score Range: 12–24 points
Description: There are some safety deficiencies or immature safety systems. Requires specific risk control actions before engagement.
High Risk Score Range: 0–11 points
Description: Unacceptable performance or system, or inadequate information. Not to be used without significant further assessment or clarification.
Should be Empty:

New Supplier Form

Workers' Compensation Insurance

Professional Indemnity Insurance

Incident & Safety Information

Scope of Services