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SpraySMART
ABN: 76 162 043 825 RTO: 40867
ENROLMENTFORM /
Course Name / Level 3 SpraySMARTChemical Accreditation / CourseCode
Course Date / Course Location
MANDATORY INFORMATION REQUIRED
Surname / First Name
Middle Name / Male / Female / Date of Birth
Residential Address
Postal Address / State / Post Code
Private Email
Mobile No. / Home No.
Town or City of Birth / Country of Birth
USI (Unique Student Identifier)
If you have a USI please write it in the following space provided
If you DO NOT already have a USI (Unique Student Identifier) you MUST supply us with ONE form of
I.D. (Identification) if you want us to generate your USI on your behalf.
This form of I.D. MUST be sighted by the trainer on the day of training.
Form of ID
(for USI application)
PLEASE SUPPLY ONE FORM OF I.D. ONLY / Driver’s Licence No. & State / Number
State
Medicare Card / Medicare
Card Number / Travel Visa / Number
Individuals Card No. / Country of Issue
Expiry Date / Citizenship Certificate No.
Card Colour
Birth Certificate / Reg No. / Immicard No.
Reg State
How would you like to receive your USI Number / Email / Text Message / Postal Mail
What is your highest school level COMPLETED (tick one box only)
Completed Year 12 / Completed Year 10
Completed Year 9 or lower / Did not go to school
Year in which you did complete that school level?
OFFICE USE ONLY / Entered By
(Initials)
Date entered in to RTO Data
Certificate Number / Date Printed
Education
Have you successfully completed any of the following qualifications? If yes tick the applicable box.
Bachelor degree of higher degree / Certificate II
Advanced Diploma or Advanced Degree / Certificate III (Trade Certificate)
Diploma or Associate Diploma / Certificate IV (advanced certificate or technician)
Certificate I / Certificate other than above
Language and Cultural Diversity
Do you speak a language other than English at home? ( if more than 1 please specify the one most used)
No / Yes / Please specify -
How well do you speak English? / Very Well / Well / Not Well
Are you of Aboriginal or
Torres Strait Islander origin? / No / Yes, Aboriginal / Yes, Torres Straight Islands
Employment
Employment Details
Of the following categories, which best describes your current employment status? (tick the box)
Full-time employment / Unpaid worker in a family business
Part-time employment / Unemployed – seeking full-time work
Employer / Unemployed – seeking part time
Self-employed – not employing others / Not employed – not seeking employment
Reason for study
Please tick one or more reasons
Job requirement / To gain extra skills / Change career
To start my own business / Personal interest / To get a job
For job advancement / Develop existing business / Self-development
Other reasons (please specify):
Disability
Do you consider yourself to have a disability, impairment or long term condition / No / Yes
If yes, please tick the areas which apply (you can tick more than one)
Hearing/Deaf / Physical / Intellectual
Learning / Mental Illness / Acquired brain impairment
Vision / Medical Condition / Other:
I certify that the above information is correct, I understand that it may be used for statistical purposes
Signature of Learner / Date
By signing this form I am agreeing that I am not under the influence of alcohol or drugs and that I am mentally capable of completing this course of study.
I am also certifying that all assessment answers provided are my own and have not been taken from another source.
Trainee Privacy: Information on this form may be used by Trainer Services Pty Ltd for trainee administration reasons, program monitoring and evaluation. The information may be provided to an authorised agency for legislative reporting requirements. It is necessary for you to provide this information for enrolment. Information provided will be held securely when no longer needed and will never be passed on to a third party for marketing purposes. You may correct any personal details provided by contacting Trainer Services Pty Ltd and completing the appropriate form.
Please tick if you do not wish to receive information on other matters from Trainer Services Pty Ltd

Trainer Services Pty Ltd

P.O. Box 234 Seven Hills NSW 1730

Freecall: 1800 872 462

Email: Web:

Enrolment Form Level 2 & 3 Dan AustinVer 2/2016