Process Owner or Function:

HR Management

Document ID:

RR-HR-FM-022

Rev. No:

03

Effective Date:

01/07/2017

Name of Form- Mobile Plant Experience Checklist & Declaration

Mobile Plant Experience Checklist

1. Please check or tick the appropriate box indicating your experience on each machine.

2. Where machines are not listed please use blank spaces to write them in.

3. Employee Name: Date Of Completion:

Excavators 3-6

Mths

6-12

Mths

1-2

Yrs

2-3

Yrs

3-5

Yrs

5+

Yrs

Graders 3-6

Mths

6-12

Mths

1-2

Yrs

2-3

Yrs

3-5

Yrs

5+

Yrs 5-30 Tonne 120/140

30-70 Tonne 12/14 G/H

70-100 Tonne 16 G/H

PC1250 120/140M

Hitachi 1200 12/14M

Hitachi 1900 16M

Hitachi 2500 24M

Hitachi 3600

Hitachi 4500

Hitachi 5500

Hitachi 8000

Komatsu PC1250

Komatsu PC2000 Loaders 3-6 6-12 1-2 2-3 3-5 5+

Komatsu PC3000 CAT Komatsu PC4000 966/989 H Komatsu PC5500 988/990 H

Komatsu PC7000 992/993

Komatsu PC8000 994F

Dump Truck 3-6 6-12 1-2 2-3 3-5 5+ Komatsu

25/30t Artic WA250

35/40t Artic WA500

CAT 769/775 WA600

CAT 777 C/D/F WA900

CAT 785 C/D/F WA1200

CAT 789 P&H L-1150

Komatsu HD 785 P&H L-1350

Komat730E P&H L-1850

Komat830E P&H L-2350

Komat930E

Komat980E

Dozers 3-6 6-12 1-2 2-3 3-5 5+ Other 3-6 6-12 1-2 2-3 3-5 5+

D6/D7 Backhoe

D8 R/T Bobcat

D9 N/T CAT/VOLVO IT

D10 N/T Artic W/Cart

D11 N/T CAT 769/773

824 C Toyota Lv’s

D375A Lighting Plant

D475A Generators

Forklifts

Drills 3-6 6-12 1-2 2-3 3-5 5+ MD6200

MD6250

MD6310

MD6540C

MD6640

P&H 250XPC

P&H 285XPC

P&H 320XPC

P&H 77XR

Please list any other relevant earthmoving plant Experience:

I declare that I have worked and have experience on the above ticked mobile plant equipment;

Signed Employee

Date:

Employer Witness

Date:

Doc No-RR-HR-FM-022 Uncontrolled when printed page 1

Form

(serious legal consequences apply to false or misleading information and can lead to employment terminated)