Individual Enrolment Form - if the individual is responsible for the course fees.
Complete this section if the individual is responsible for the course fees. All fields must be filled out.
Choose Course GI Core & Underground combined – Metalliferous (Brisbane) - $775.00GI Core – Metalliferous (Brisbane) - $600.00GI Underground - Metalliferous (Brisbane) - $330.00GI Core & Underground combined – Metalliferous (Townsville) - $620.00GI Core – Metalliferous (Townsville) - $550.00GI Underground – Metalliferous (Townsville) - $265.00GI Core Refresher - Metalliferous (Townsville) - $385.00GIQ Core – Coal (Townsville) - $775.00GIQ Bridging – Coal (Townsville) - $550.00QMS 123 Site Supervisor and Safety Representative (Townsville) - $620.00G2 - Carry out risk management processes (Townsville) - $560.00GI Fire – Use Portable Fire Fighting Equipment (Townsville) - $75.00GI First Aid – Apply Initial Response First Aid / Perform CPR (Townsville) - $75.00Low Voltage Rescue (Townsville) - $75.00Perform CPR / Low Voltage Rescue combined (Townsville) - $110.00Senior First Aid (Townsville) - $205.00Confined Space – Worker (Townsville) - $345.00Confined Space – Supervisor (Townsville) - $560.00Working Safely at Heights (Townsville) - $345.00White Card General Construction Induction (Townsville) - $130.00Asbestos B (Townsville) - $152.00 Course Date 12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 20112012
Name Student Date of Birth 12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year Street Address Suburb State QLDNSWVICACTSAWANTTAS Postcode Suburb Email Phone Mobile Driver's Licence No. Exp Date 12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year
I have read and agree to the terms and conditions relevant to the course enrolment and attendance.
PAYMENT IS REQUIRED BEFORE ENROLMENT. Upon submission of this form you will be redirected to the payment area. Please find the appropriate course in the list and click the 'add to cart' button. Your selection will be added to the Shopping Cart in the left column. Ensure the course listed is correct then click on 'Go to Checkout' to make payment. If payment is via PayPal a surcharge will be incurred. This fee represents 2.4% (+$0.30) of the total payment amount. This fee is the service fee charged by PayPal. This fee is non-refundable.
If this page doesn't redirect upon submission click here to visit the store and make your payment. You will be notified of your commencement date once payment has been confirmed.
Before submitting this form, check all your details are correct then enter the security code below.
Complete this section if a company is responsible for the course fees. All fields must be filled out.
Company Name* Company Contact Name* Company Phone*
Choose Course GI Core & Underground combined – Metalliferous (Brisbane) - $775.00GI Core – Metalliferous (Brisbane) - $600.00GI Underground - Metalliferous (Brisbane) - $330.00GI Core & Underground combined – Metalliferous (Townsville) - $620.00GI Core – Metalliferous (Townsville) - $550.00GI Underground – Metalliferous (Townsville) - $265.00GI Core Refresher - Metalliferous (Townsville) - $385.00GIQ Core – Coal (Townsville) - $775.00GIQ Bridging – Coal (Townsville) - $550.00QMS 123 Site Supervisor and Safety Representative (Townsville) - $620.00G2 - Carry out risk management processes (Townsville) - $560.00GI Fire – Use Portable Fire Fighting Equipment (Townsville) - $75.00GI First Aid – Apply Initial Response First Aid / Perform CPR (Townsville) - $75.00Low Voltage Rescue (Townsville) - $75.00Perform CPR / Low Voltage Rescue combined (Townsville) - $110.00Senior First Aid (Townsville) - $205.00Confined Space – Worker (Townsville) - $345.00Confined Space – Supervisor (Townsville) - $560.00Working Safely at Heights (Townsville) - $345.00White Card General Construction Induction (Townsville) - $130.00Asbestos B (Townsville) - $152.00 Course Date 12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 20112012 Course Cost $ Number of Students (Maximum 4 students per form. Submit additional forms if more than 4 students are enrolling.) Total Cost $
Name Date of Birth 12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year Email Phone Mobile
Choose your method of Payment ---PayPal (visit http://www.worksafeconnect.com/store to complete payment)Credit card (Visa, Master Card)Direct Deposit (Bank: ANZ, Hermit Park BSB: 014592 A/C #: 479067505 A/C Name: WorkSafe Connect)Purchase order (Approved account holders only)
I am authorised to make this booking on behalf of the company stated above. I am responsible for ensuring the person/s being enrolled are aware of all the terms and conditions of their enrolment and attendance to the course. The company, I and the student/s agree to the terms and conditions relevant to payments, cancellations, confirmations, transfers, admin fees and privacy.
PAYMENT IS REQUIRED BEFORE ENROLMENT. Upon submission of this form you will be redirected to the payment area. Please find the appropriate course in the list, enter number of students in the quantity field, then click the 'add to cart' button. Your selection will be added to the Shopping Cart in the left column. Ensure the course listed is correct then click on 'Go to Checkout' to make payment. If payment is via PayPal a surcharge will be incurred. This fee represents 2.4% (+$0.30) of the total payment amount. This fee is the service fee charged by PayPal. This fee is non-refundable.
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