Issued to Company/Contractor: Nature of Work: Aera: Aera: Time Commences: : HH MM AM PM Date Commences: Date Format: DD slash MM slash YYYY Time Expires: : HH MM AM PM Date Expires: Date Format: DD slash MM slash YYYY 1st Person Carrying out work: Your Email Your Email 2nd Person Carrying out work: 3rd Person Carrying out work: Issued By: Accepted By: Extinguisher Present? Yes No date_range Date Extinguisher(s) being used were last tested. Area clear of combustibles/flammables? Yes No Area fire alarm disconnected/protected? Yes No Familiar with how to raise alarm and with nearest exit? Yes No Have you checked the area before commencing? Yes No Protect/cordon off adjacent area? Yes No Hot work equipment in good working order? Yes No
