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Safe Business

Mentor Program - Expression of Interest Registration Form

Please enter your registration details:

Corporate Details
*Legal Business Name  
Trading As  
*ABN  
*Workers Compensation Policy Number  
Renewal Date  
*Name and Title of Head Executive  
*Industry Type
Manufacturing Construction
Retail Consumer Services
Transport Community Services
Agriculture Other
Nominated Mentor Program Company Representative
*Applicant's First Name  
*Applicant's Last Name  
*Position  
*Job Title  
*Business Street Address Line 1  
Business Street Address Line 2  
Business Street Address Line 3  
*Suburb  
*State  
*Postcode  
Country  
Business Postal Address  
Suburb  
Postcode  
State  
*Work Phone  
Work Fax  
Mobile  
*Email  
*What region are you located in?  
*Preferred method of communication
Phone Email
Fax
Second Nominated Mentor Program Company Representative (if applicable)
Name  
Business Street Address Line 1  
Business Street Address Line 2  
Business Street Address Line 3  
Suburb  
State  
Postcode  
Work Phone  
Work Fax  
Mobile  
Email  
Preferred method of communication
Phone Email
Fax

Privacy Statement
Personal information collected in this form is collected by WorkCover NSW in accordance with the Privacy and Personal Information Protection Act 1998. WorkCover NSW respects your privacy and is committed to protecting your personal information. We collect your personal information to provide our services to you, to improve the quality of our services and to provide you with information about other services we offer. You are required to provide this information in order for us to process your registration form. Failure to provide the information may result in us not being able to process your registration form. You have the right to access and correct your personal information. You can do this at any time by contacting WorkCover NSW’s Assistance Service on 13 10 50 or in writing to Ground Floor 92-100 Donnison Street GOSFORD NSW 2250. Further information on our privacy policy is available at www.workcover.nsw.gov.au




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