Customer Service Registration Form

Please complete all required information, on submitting this form a tax invoice will be emailed to the accounts payable email address and can be paid by EFT or credit card.

Contact Name :

Contact e-mail :

Contact No : (If entering landline number, include area code)

PCBU : (Name of Company or Organisation)

Accounts payable email :

Purchase Order Number : (Enter purchase order number if applicable)

Enter Course Date/s :

Select Course :

Participant/s details:

Please enter a valide email address and phone number for each participant listed.
If entering landline number, include area code.

I am authorised by each of the persons or PCBUs included in this form (including all partners/principals/directors, if applicable) to:
a) complete this form; and
b) make these declarations
i) payment for all participants listed will be made by the PCBU within 14 days of the invoice date or before the course start date, if les than 14 days of the invoice date; and
ii) any cancellations will be made 21 days before the course start date;and
iii)all fees paid will be retained by Job Safety Assistance Pty Ltd for cancellations made less then 21 days before the course start date; and
e) acknowledge and accept the full "Registration Terms" on their behalf.
Enter the number as shown : - verification image, type it in the box