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Unit 7, 148-150 Canterbury Road Bankstown NSW 2200
(02) 8292 0111
Unit 3, 1 Melissa Place Kings Park (Blacktown) NSW 2148
(02) 8292 0111
20 Third Avenue, Blacktown (Blacktown City) NSW 2148
(02) 8292 0111
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Implementation Traffic Control Recertification Enrollment From
Enrolment
Implementation Traffic Control Recertification
1. Personal Details
Surname:
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Given Names:
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Title: Ms/Mrs/Mr
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Date of Birth:
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(dd/mm/yyyy)
Gender:
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Male
Female
USI Number (click
here
if you do NOT have one)
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Phone No:Home
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Phone No:Work
Mobile
Email:
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Confirm Email Address:
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Residential Address:
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City/Town:
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State:
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Post Code:
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As Above.
Postal Address:
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City/Town:
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State:
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Post Code:
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Are you of Aboriginal origin?
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Please Select
Yes
No
Are you of Torres Strait Islander origin?
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Please Select
Yes
No
Were you born in Australia?
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Please Select
Yes
No
If not, what Country were you born in?
2. Education & Language
Are you still attending secondary school?
*
Please Select
Yes
No
If yes, which school?
What is your highest COMPLETED school level?
*
Please Select
Completed Year 12
Completed Year 10
Completed Year 8 & below
Completed Year 11
Completed Year 9
No School or Overseas Schooling
What year did you complete your highest level?
Are you currently employed?
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Please Select
Yes
No
Are you employed Full time or Part time?
Please Select
F/T
P/T
Have you completed any of the following in Australia?
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Please Select
Bachelor Degree or Higher
Certificate IV (or Advanced Certificate/Technician)
Certificate I
Advanced Diploma or Associated Degree
Certificate III (or Trade Certificate)
Diploma or Advanced Diploma
Certificate II
Other
No
If Other : Please detail
Do you speak a language other than English at home?
Please Select
Yes
No
If yes, what language, other than English is spoken at home?
How well do you speak English?
Very Well
Well
Not Well
Not at all
Do you feel that you may require assistance with Language, Literacy and/or Numeracy?
No, Not at all
Some Assistance
Lots of assistance
Do you consider yourself to have a permanent disability, impairment or long term condition?
Please Select
Yes
No
If YES, then please indicate the areas. (You may indicate more than one area)
Please Select
Acquired Brain Injury
Hearing/Deaf
Intellectual
Learning
Mental Illness
Physical
Vision
Medical Condition
Other
3. Course and Employment Details
Name of Employer(if applicable):
Manager ’ s Name:
Do you hold a current White Card?
*
Please Select
Yes
No
Can you provide evidence of this?
*
Please Select
Yes
No
Do you hold a current RTA/RMS Blue or Yellow Card?
Please Select
Yes
No
Do you hold any other relevant Certifications/Licences/Tickets/ Permits/Statements of Attainment/qualifications?
Please Select
Yes
No
Have you recently (past 12 months, more than twice) worked as an approved Traffic Controller in NSW?
Please Select
Yes
No
N/A
Have you recently (past 12 months) worked in a role where you have had to implement Traffic Management Plans in NSW?
Please Select
Yes
No
N/A
The code and name of the qualification you are enrolling in:
How would you like to complete this course?
Online
Implementation Traffic Control - Terms and Conditions
Via Correspondence
Implementation Traffic Control - Terms and Conditions
Participant Declaration & Privacy Statement
I have read and understood the course information and the Participant/Client Information Handbook made available to me
I understand the roles and responsibilities as the participant and that of the trainer / assessor. I understand the pathways and options available to me for training and assessment.
I declare that the information supplied on this form is correct and complete.
I hereby agree to abide by the RTO policies and procedures relating to fees, charges and regulations of the organisation.
I declare that the information supplied on this form is correct and complete.
I agree that personal information and records (this may include written, verbal, photographic and other formats) collected by the Registered Training Organisation (RTO) may be used by the RTO for research, statistical analysis, program evaluation and internal management purposes, used by government departments for audit, research, statistical analysis, program evaluation and used for promotional and commercial purposes
I understand that my personal information will only be disclosed to other third parties in accordance with the law and with the appropriate legal documents or agreement/ permission in writing by myself.
I have read and understood the terms and conditions set out above.
Security Code:
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