Fire Tag and Certification Request Form

This form must be completed in full to ensure the installation of the door and hardware meets the relevant Australian Standard AS1905.1-2015.

Customer Name

Customer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job Name

Job Address

Radiant Invoice/Job No:

Frame Details

Frame Material

Fixed to:

Masonry

Block

Plaster

Other

Fixed to Other (Please specify)

Method of Fixing

(eg Wire ties, Dyna bolts, etc)

Frame is core filled

Yes

Frame is core filled with

Non shrink Grout

Fire rated plaster

Door Details

Single / Double Door

Door No.

Hour Rating

Width of Door/s Leaves

Height of Door/s Leaves

Thickness of Door/s

Door Facing

(eg Paint Ply)

Gap between door and door frame / floor

Top Gap

Hinge Gap

Lock Gap

Bottom Gap

Hardware installed to door/s

Lock Type

(eg: Lockwood 3772)

Backset

(if cylindrical)

Lock Height

(eg: 1032mm)

Closer Type and Quantity

Additional Hardware

Example: Fire bolts, Top latch, Aluminium Meeting stile, etc

Door Installer

I (Name),

First Last

Of Company

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Of Company

Certify that,

a) each of the building components relating to the discipline and scope of work identified below:

has been assessed by me or a person (chosen by me) who was properly qualified and experienced to do so, and
has been installed to a standard meeting the applicable Building Code of Australia 2022 requirements and relevant Australian Standards listed below in appendix A and to be capable of performing to a standard not less than that required.

b) The information contained in this certificate is, to the best of my knowledge and belief, true and accurate.

Signed

(Name or initials)

Date

Contact Number

Engineering qualifications / Accredited No.

Accreditation / License Number

Accredited by

(eg Department of Fair Trading)

Comments

Customer / client