Perth Region Enrolment Form

Perth Farm Business Resilience Program Enrolment Form

This is an 8 week program with 4 in-person workshops dates. You will need to attend all 4 days of the in-person training.

Mentoring is completed virtually.

Dates for the in-person workshops are:

4-5 July

10-11 August
Do you have 1 or 2 Applicants?*

1 Applicant2 Applicants
Applicant 1
Name:*

First NameLast Name
Date of Birth

DayMonthYear
Date
E-mail Address:
Phone Number:*

Area CodePhone Number
Mailing Address:*

Street Address

Street Address Line 2

CityState

Postcode
Street Address:

Street Address

Street Address Line 2

CityState

Postcode
Same as Mailing Address

Applicant 2
Name:*

First NameLast Name
Date of Birth

MonthDayYear
Date
E-mail Address:
example@example.com
Phone Number:*

Area CodePhone Number
Mailing Address:*

Street Address

Street Address Line 2

CityState

Postcode
Street Address:*

Street Address

Street Address Line 2

CityState

Postcode
Same as Mailing Address

Farm Business Details
Business Entity Name
Location Shire
ABN
Size of Enterprise
Hectares
Your Farming Operations

% of farm business:
Broadacre cropping
%
Livestock
%
Horticulture/Vegetables
%
Tourism
%
Beekeeping/Apiculture
%
Viticulture
%
Pastoral
%
Aquaculture
%
Other
Name and %

Previous strategic farm business planning programs
Have you attended a previous program such as Drought Pilot Program, Plan, Prepare, Prosper Program, Planning for Profit, Succession Planning, other?*

YesNo
Tick all that apply

Drought Pilot ProgramPlan, Prepare, Prosper ProgramPlanning for ProfitSuccession PlanningOther
Please advise of Program Name, Year, and Town.
Your Strategic Farm Business Planning
Do you have a current strategic farm business plan?*

YesNo
When was it last updated?

Authorisation and Certification
I hereby authorise Value Creators to supply such information as requested by the Department of Primary Industries and Regional Development related to this FBRP Enrolment Form*

YesNo
I confirm I am authorised to make this Certification*

YesNo
Name of Person making this Certification*

First NameLast Name
Signature*

Clear

Deposit*

Deposit - 1 Applicant$500.00AUD

Deposit for 1 Applicant

Deposit - 2 Applicants$1,000.00AUD

Deposit for 2 Applicants

Total $0.00AUD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty: