Application Status:

1. Occupier Details
Name of Workplace
Reference Number		Application Date
Workplace Category		Operation Date
Male Employees		Female Employees
TIN		Tax Payer Name
Nature of Work

2. Contacts
Telephone		Post Address
Email		Fax No.

3. Location
District		County
SubCounty		Location Details

4. Steam Boilers
#	Type, description and distinctive number:	Country of manufacture	Year of Manufacture	Last Examination Date	Last Examiner	Maximum Permissible Working Pressure
No Steam Boilers!

5. Mechanical Energy Usage		6. Other Equipment
Steam		Lift
Electric Motors		Cranes, Winches, Fork Lifts etc
Oil Engines		Block and Tackle, Chain Blocks
Other:		Air Receivers
		Gas Plant

7. Waste Management
a) Whether you use or intend to use industrial waste treatment plant	Yes	No
b) Method of handling effluents.
Septic Tank	National Provider	Other:

8. Welfare Provisions
c) Whether you have made provision for (Tick what is applicable)
Sanitary Installation	Washing Facility	Clothes Facility	First Aid	Drinking Water	Emergency Plan

9. Hazardous Material
a) Whether you use or intend to use hazardous chemicals:
Toxicity:		N/A
Chemical Properties:		N/A
Physical Properties:		N/A
Irritant Properties:		N/A
Corrosive Properties:		N/A
Allergic and sensitizing properties:		N/A
Carcinogenic Effects:		N/A
Tetratogenic Effects:		N/A
Mutagenic Effects:	N/A
b) Their effects on the reproductive system.
N/A
c) Whether hazardous substances are distinctively labelled and an appropriate chemical safety data sheets available.
Yes			No

10. Attach Safety Data Sheets or any required Document(s)

No Attachments!

Process Flows
Application Assignment
Assigned By	Assigned Date	Assigned To	Financial Year/Quarter
			-

Application Assessment
Assessment By	Assessment Date	Assessed Amount	PRN Generated	Financial Year/Quarter
		0		-

Tax Head
Tax Head			Dissatisfied?
>>>>>>			-

Assessment Approval
Approved By	Approval Date	Approved Amount	Financial Year/Quarter
		0	-

PRN Details
PRN	Search Code	PRN Date	Amount	Financial Year/Quarter
			0	-

PRN Payment
Payment Date	Amount	Expiry Date	Financial Year/Quarter
	0		-

Certification Assignment
Assigned By	Assigned Date	Assigned To	Financial Year/Quarter
			-

Certification Processing
Draft Date	Approved Status	Approved By	Approved Date	Financial Year/Quarter
				-

Client Details
Name		TIN
TIN Email		TIN Telephone
Sec Email		Sec Telephone