Please complete all required information, on submitting this form a tax invoice will be emailed to the accounts payable email address and can be paid by EFT or credit card.


Contact Name :


Contact e-mail :


Contact No : If entering landline number include area code.


PCBU : (Name of Company or Organisation)


Accounts payable email :


Select Course Date/s : 5 days - 10 to 14 July 2017 - Coffs Harbour 5 days - 21 to 25 Aug 2017 - Townsville 5 days - 28 Aug to 1 Sept 2017 - Cairns 5 days - 18 to 22 September 2017 - Darwin 5 days - October 2017 - TBA 5 days - 13 to 17 November 2017 - Wodonga 5 days - February 2018 - TBA 5 days - March 2018 - TBA 5 days - April 2018 - TBA 5 days - May 2018 - TBA 5 days - June 2018 - TBA


Participant/s details

Please enter a valide email address and phone number for each participant listed.

If entering landline number include area code.

Yes I am authorised by each of the persons or PCBUs included in this form (including all partners/principals/directors, if applicable) to:

a) complete this form; and
b) make these declarations

i) payment for all participants listed will be made by the PCBU within 14 days of the invoice date or before the course start date, if les than 14 days of the invoice date; and
ii) any cancellations will be made 21 days before the course start date;and
iii)all fees paid will be retained by Job Safety Assistance Pty Ltd for cancellations made less then 21 days before the course start date; and

e) acknowledge and accept the full "Registration Terms";
on their behalf.

Enter the number as shown : -
.