ENTRY FORM
HSEM Incident/Hazard Reporting System - Renaming Competition

First Name: ______

Last Name: ______

Staff Id: ______

Department: ______

Contact number: ______

Email address: ______

Please enter your name submissions below: (up to 5 submissions allowed):

Name submission 1:

Name submission 2:

Name submission 3:

Name submission 4:

Name submission 5:

☐ I have read and accept the Terms & Conditions of entry

Please email your entry form to Health, Safety and Emergency Management by close of business Wednesday by 7 September 2016.

Terms and Conditions

  1. Instructions on how to enter and other details contained within promotional advertisements for this competition form part of the conditions of entry.
  2. By entering the competition, entrants agree to abide by these Terms and Conditions.
  3. The Terms and Conditions of this competition are governed by the laws of the State of Western Australia.
  4. The competition is being run by Curtin University of Technology, GPO Box U1987, Perth, Western Australia, 6845 (“Curtin”).
  5. TheHSEM Incident/Hazard Reporting System Renaming Competition (“the competition”) commences at 9am Australian Western Standard Time (AWST) on Monday 29 August 2016.
  6. The closing time for entering the competition is 5pm AWST on Wednesday, 07 September 2016
  7. Entry to the competition is limited to Curtin University staff.
  8. To enter the competition, the entrant must:

(a)Complete the entry form which can be found on the HSEM website (

(b)Submit the entry form via email to the following email address: mailto: before the closing time.

  1. 5 name submissions is allowed per entrant.
  2. Entry to the competition is free. Entrants will be responsible for all costs associated with entering the competition, which may include costs associated with accessing the internet.
  3. There will be one (1) prize. This prize will be a $100 Coles/Myer gift card.
  4. The winner will be determined by the HSEM department voting for the best entry.
  5. The prize winner will be contacted within ten (10) days of the voting taking place viathe email address supplied by the entrant on the event registration form.
  6. If the prize winner is under the age of 18 years, the prize will be awarded to the winner’s parent or legal guardian.
  7. The prize may be collected in person by the prize winner.
  8. The prize winner, or if under the age of 18 years their parent or legal guardian, may be required to provide evidence of their identity (such as photographic ID, birth certificate or current passport) when receiving the prize.
  9. The prize winner will be responsible for all costs associated with collecting and using the prize.
  10. By entering the competition the entrant agrees that they are over the age of 18 years, of if under the age of 18 years, have their parent’s or legal guardian’s consent to enter the competition.
  11. The prize is not redeemable for cash or an alternative prize.
  12. The prize is not transferrable.
  13. The prize winner’s name will be published on the Curtin website. By entering the competition, entrants grant Curtin permission to use their full name on its website.
  14. Curtin is not responsible in any manner whatsoever for any problems or any financial costs incurred, or any combination thereof, including any injury or damage to participants or any other persons related to or resulting from participation in this competition.
  15. Curtin accepts no responsibility and shall not be held legally liable or responsible for any accident, loss, injury or damage to any individual or property whether direct or indirect, whether in contract, tort, negligence or otherwise arising out of or in connection with the competition or the prize, either during or after the competition.
  1. Entry into the competition signifies acceptance of all conditions. Entrants are required to abide by the Terms and Conditions as presented.
  2. Curtin's decision will be final and no correspondence will be entered into.
  3. Personal information provided by an entrant to Curtin for the purpose of entering the Competition will be collected, used and disclosed in accordance with Curtin’s Privacy Statement. A copy of the privacy statement is available at Personal information collected will be kept strictly confidential and will not be sold, reused, rented, loaned or otherwise disclosed to any third party otherwise than in accordance with the Curtin privacy statement and these Terms and Conditions.