Contact Name : * *


Contact e-mail : *


Contact No : * (include area code if landline)


PCBU : * (Name of Company or Organisation)


Location : * State : * Post Code : *


Accounts payable email : * (Invoices will be sent to this address)


Purchase Order: (Enter purchase order number if applicable)


Select Course Dates : *


Participant/s details:

Please enter a valide email address and phone number for each participant listed.
If entering landline number include area code.

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* I am authorised by each of the persons and/or PCBUs listed in this form (including all partners/principals/directors) 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 less than 14 days of the invoice date; and
ii) any cancellations will be made by email 15 business 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 15 business days before the course start date;and
iv) all outstanding invoices issued for the participant/s cancelling less then 15 business days before the course start date remain due and payable in full;and
e) acknowledge and accept the full "Registration Terms" on their behalf.


Enter the number as shown : * - verification image, type it in the box
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