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

Student Enrolment Form

You are enrolling in a Health and Safety Representatives Training

Course Start date: 17 Mar 2025

Mine Training Australia
Health and Safety Representatives Training
5 Day Course
8.00am - 4:00pm

At Pivot Institute / Mine Training Australia
46 Edward Street
Osborne Park WA 6017

Bring your laptop and charger.

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

Email *

Confirm Email *

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 *

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.

Upload an attachment

(To upload multiple files, please Zip the files together, and upload the Zip file)

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

Payment is Optional for this course

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