Form OSHA-70 Application for Accreditation to Perform Gear Certificat

Application for Accreditation to Perform
Gear Certification Functions
No accreditation may be
granted unless a completed
application form has been
received (29 CFR 1919).

1.

U.S. DEPARTMENT OF LABOR
Occupational Safety and Health Administration

Pursuant to the Occupational Safety and Health Act and to the Longshoremen’s and
Harbor Workers’ Compensation Act, as amended, and regulations issued thereunder, all
persons seeking accreditation, in whole or in part, to perform gear certification functions
are required to file an original and duplicate copy of this application form with the
Occupational Safety and Health Administration, Attn. U.S. Department of Labor, Office of
Maritime Enforcement, Room N-3610, 200 Constitution Ave, NW, Washington, D.C.
20210. The information furnished in this form shall be certified by the applicant. If
applicant is an agency or organization, a responsible officer shall execute the
certification.

Form Approved
OMB No. 1218-0003
(See reverse for Paperwork
Reduction Act Notice.)

Work applied for (check)

 a.
 b.
 c.
 d.

 e. Shore-based material handling devices
 f. Other (explain)_________________________________________
 g. Limitations (e.g., work applied for limited to

Full gear certification functions-vessels
Loose gear and/or wire rope testing
Heat Treatments

cranes, barge-mounted equipment, etc.)

Non-destructive examination (state methods)

____________________________________________________
2.

Full Name of Applicant

3.

Telephone

4.

Business Address

5.

Locations in which applicant intends to operate

6.

List four (4) references who can furnish information regarding work performed by applicant (include full name of individual to be contacted, title, and
full address):

a.__________________________

b.__________________________

c.___________________________

d.__________________________

___________________________

___________________________

____________________________

____________________________

___________________________

___________________________

____________________________

____________________________

___________________________

___________________________

____________________________

____________________________

7.

Applicable types of work performed in the past. (Attach list noting amount and extent of such work performed within the past 3 years, for whom
done, to whose survey, to whose requirements, listing representative vessels and/or equipment involved and attaching representative job orders, if
available, or equivalent evidence.)

8.

Description of testing instruments and/or heat treatment furnaces, make and model of non-destructive examination equipment, etc., if any. Attach
test reports less than 6 months old giving accuracy data of physical testing equipment.

9.

Submit a resume of the training and experience of each individual who will be testing, examining, inspecting and/or heat treating cargo gear and
other equipment. This shall include the applicant and/or all responsible managerial, supervisory, and survey personnel who may be acting on
behalf of the applicant.

The undersigned certifies that all statements made in this application are true to the best of his/her knowledge and belief and grants permission for the
Occupational Safety and Health Administration to contact any persons relative to statements made herein. If granted accreditation, it is understood that
the undersigned will comply with all applicable regulations of the Occupational Safety and Health Administration.

Signature_________________________________________________

Title_____________________________________________________

Date_____________________________________
OSHA 70 Rev. January 2011

Paperwork Reduction Act Notice
Public reporting for this collection of information is voluntary and is estimated to average 45 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
However, any person seeking accreditation is required to complete the OSHA 70 Form. Persons are not required to respond to the collection of
information unless it displays a currently valid Office of Management and Budget (OMB) control number. If you have any comments regarding this
estimate or any other aspect of this information collection, including suggestions for reducing this burden, please send them to OSHA’s Office of
Maritime Enforcement, Room N-3610, 200 Constitution Avenue, N.W., Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM OR COMMENTS TO OMB