Pivot Solutions Pty Ltd trading as Mine Training Australia and Pivot Institute

Student Enrolment Form

You are enrolling in a DEMIRS S26 Exam Preparation Course - F2F

Course Start date: 01 Aug 2025

Course time 8:00am to 3:00pm
Practical Law Exam Preparation 1 Day Course face to face at 46 Edward Street, Osborne Park.
Please bring in your laptop and charger and WHS Act and Regulations (mines) books.

Please fill in the Registration form below. Fields with a red * are required.

Terms & Policies

I have read and I agree to the Privacy Statement

I have read and I agree to the terms and conditions. *

Student details

Enter your full name

Title

Family name (surname)*

First given name/s*

Second given name (middle)

Enter your birth date

Date of Birth *

Please select your Gender

Gender *

Enter your contact details

Your Email Address *

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Alternative email address (optional)

Additional Email

This email address will be used as a CC email address on communications to you, please use this field to indicate if we need to CC another person / company in your communications.

Mobile *

Home Phone

Work Phone

Preferred Contact *

Your Company of employment

Company

Please enter the details for your your next-of-kin / Emergency Contact

Full Name *

Phone/Mobile *

Relationship *

Address(es)

What is the address of your usual residence?

Please provide the physical address (street number and name not post office box) where you usually reside rather than any temporary address at which you reside for training, work or other purposes before returning to your home.

If you are from a rural area use the address from your state or territory’s ‘rural property addressing’ or ‘numbering’ system as your residential street address.

Building/property name is the official place name or common usage name for an address site, including the name of a building, Aboriginal community, homestead, building complex, agricultural property, park or unbounded address site.

Building/property name

Flat/unit details

Street or lot number (e.g. 205 or Lot 118) *

Street Name *

Suburb, locality or town *

Postcode *

State/Territory *

What is your postal address (if different from above)?

I have a postal address that is different to the residential address provided

Building/property name

PO Box

Flat/unit details

Street or lot number (e.g. 205 or Lot 118)

Street Name

Suburb, locality or town

Postcode

State/Territory

RTO Questions

RTO Specific Questions

ID Drivers Licence and/or Medicare Number *

Class Start Date and Study Mode *

Company Purchase Order# if applicable

Student Status: Aus Citizen/PermVisaHolder/Subclass# *

If Funded: Concession Eligibility? eg HCC/PCC

How did you hear about us? *

Misc.

Language, Literacy & Numeracy

LLN Assistance
I require Language, Literacy and Numeracy assistance.

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Attachment (if applicable) (pdf, doc, docx, zip, png, jpeg - 3MB maximum)

Is there anything else we need to know, in regards to your enrolment?

Additional Notes

Payment

Who is paying for this enrolment? (Invoice Type)

Payment is Optional for this course

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