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  3. Certificate III in Community Pharmacy Course Form

Enrolment    Certificate III in Community Pharmacy Course

1. Personal Details
Surname: *
Given Names: *
Title: Ms/Mrs/Mr *
Date of Birth: *
 (dd/mm/yyyy)
Gender: *  Male
 Female
USI Number (click here if you do NOT have one) *
Phone No:Home *
Phone No:Work
Mobile
Email: *
Confirm Email Address: *
Residential Address: *
City/Town: *
State: *
Post Code: *
As Above.
Postal Address: *
City/Town: *
State: *
Post Code: *
Are you of Aboriginal origin?*  
Are you of Torres Strait Islander origin?*  
Were you born in Australia?*  
If not, what Country were you born in?
2. Education & Language
Are you still attending secondary school?*  
If yes, which school?
What is your highest COMPLETED school level?*  
What year did you complete your highest level?
Are you currently employed?*  
Are you employed Full time or Part time?  
Have you completed any of the following in Australia?*  
If Other : Please detail
Do you speak a language other than English at home?
If yes, what language, other than English is spoken at home?
How well do you speak English? Very Well   
Well    
Not Well   
Not at all
Do you feel that you may require assistance with Language, Literacy and/or Numeracy? No, Not at all    
Some Assistance    
Lots of assistance
Do you consider yourself to have a permanent disability, impairment or long term condition?
If YES, then please indicate the areas. (You may indicate more than one area)
3. Course and Employment Details
Name of Employer(if applicable):
Manager’s Name:
Do you hold a current White Card?*  
Can you provide evidence of this?*  
Do you hold a current RTA/RMS Blue or Yellow Card?  
Do you hold any other relevant Certifications/Licences/Tickets/ Permits/Statements of Attainment/qualifications?
Have you recently (past 12 months, more than twice) worked as an approved Traffic Controller in NSW?
Have you recently (past 12 months) worked in a role where you have had to implement Traffic Management Plans in NSW?
The code and name of the qualification you are enrolling in:

How would you like to complete this course?

  Online
 Via Correspondence
Participant Declaration & Privacy Statement
  • I have read and understood the course information and the Participant/Client Information Handbook made available to me
  • I understand the roles and responsibilities as the participant and that of the trainer / assessor. I understand the pathways and options available to me for training and assessment.
  • I declare that the information supplied on this form is correct and complete.
  • I hereby agree to abide by the RTO policies and procedures relating to fees, charges and regulations of the organisation.
  • I declare that the information supplied on this form is correct and complete.
  • I agree that personal information and records (this may include written, verbal, photographic and other formats) collected by the Registered Training Organisation (RTO) may be used by the RTO for research, statistical analysis, program evaluation and internal management purposes, used by government departments for audit, research, statistical analysis, program evaluation and used for promotional and commercial purposes
  • I understand that my personal information will only be disclosed to other third parties in accordance with the law and with the appropriate legal documents or agreement/ permission in writing by myself.
 
 
I have read and understood the terms and conditions set out above.
Security Code: *
Just to further protect your information by making sure you are not a robot, please complete the following before sending.