Instructed Person New User Registration Form 2014 V2

Your Details (Student)
Please complete the following details to enable our support desk to register you for the training. Some questions are used to prove your identity when contacting our support desk to meet Privacy Act and Online Training Identification requirements.
Full Name as it appears on your Drivers License (or other approved Photo Identification e.g. Country travel passport)*

First NameMiddle NameLast Name
Do you have a Middle Name?*

YesNo
Your Middle Name
Do you have a middle Name? Enter it here.
Drivers License Number
State
Country
Also know as
Do you have another name that you are commonly known by?
Date of Birth*

DayMonthYear
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Students personal email address. THIS CAN BE THE STUDENTS PERSONAL WORK EMAIL. This is required for communication with the student for general communications & security identification purposes? IT MUST BE DIFFERENT TO THE EMPLOYER CONTACT EMAIL BELOW*

Confirmation EmailMANDATORY- Do not have an email address? Create one at Gmail": https://www.google.com/intl/en-GB/mail/help/about.html
Students Telephone Number*
Students Mobile Number*

Your Employer
Your Employers Registered Business Name*
Your Employers Trading Name
Your Employers Australian Business Number (ABN)*
Lookup at: http://abr.business.gov.au/
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Your Employers Contact Person*
Your Employers Telephone Number*
Your Employers Email*
Please ConfirmYour Employers Email*
In Case of Emergency (ICE)
"In Case of Emergency" Contact Telephone Number*
"In Case of Emergency" Contact Person*

First NameMiddle NameLast Name
"In Case of Emergency" Contact Person Mobile Phone Number*

Privacy and Confidentiality

Please provide the name of a person within your organisation who can request information on your behalf.
I understand that the information being collected in this form is to be used by WGL Enterprises Pty Ltd on behalf of TESI*

Yes
I confirm that the information supplied by me is accurate and correct*

Yes
Authorised Person Within Your Organisation
Please provide the name of an authorised person(s) who can make contact with us on your behalf.
Name*

First NameMiddle NameLast Name
Contact Number*
Enter the message as it's shown*
Should be Empty:

REGISTER HERE TO ACCESS THE TESI PSSR INSTRUCTED PERSON COURSE ONLINE