Asterisk * indicates a mandatory field. Course Name: * Introduction to Corporate Governance workshopCertificate IV in Business (Governance)Diploma in Business (Governance)Two-day governance workshop Course ID: * Course Location: * Course Dates: * About you Title: - None -MrMsMissMrs First name: * (as you want it to appear on your certificate) Last name: * I prefer to be called: Gender: * Male Female Date of birth: Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999 Are you an Aboriginal or Torres Strait Islander person?: * Yes No I am: Aboriginal Torres Strait Islander Your contact details Home address: * Town/suburb: * State: * - Select -ACTNSWNTQLDSAVICWATAS Postcode: * Is your postal address different from your home address?: Yes No, you can post to my home address Postal address: * Best phone number: * Alternative phone number: Email: Fax: Emergency contactsWho should we contact in case of an emergency? Name: Phone: Your role in the corporation My corporation's name is: Indigenous Corporation Number (ICN): My role in the corporation: - None -DirectorMemberContact person/secretaryStaffOther Please describe your role: How long have you performed this role? Years: Months: Employment status: Full-Time Part-Time Student Unemployed If your application is successful, we will need written confirmation from your employer, on company letterhead, that they will release you from your work duties to attend the course. Your studies Please confirm you have completed a Certificate IV in Business (Governance): * Yes Please confirm you have completed a pathway workshop: * Yes Where and in what year did you complete it?: Where and in what year did you graduate?: In your own words, tell us about your role in the corporation and why you'd like to complete this course: * Note: this section must be completed by the applicant Travel & accommodation If you are traveling to attend the training, do you require assistance?: Yes No What assistance do you need?: Will you travel by car?: Where there are several participants from a corporation we would expect them to car pool. Yes No Do you require accommodation during the workshop? (Twin share rooms only): Yes No Who would you like to share a room with?: Health & wellness Please advise us if you have any medical conditions, mobility issues or dietary requirements: Finally... Are you sending this request on behalf of someone else?: No, it's for myself Yes, someone else would attend the training Your name: Your phone number: Your relationship to the person who would attend the training: Do you have any other comments?: Please note that a request for training does not guarantee you a place.