WorkCover assisting you to keep your business safe and successful

Safe Business

Mentor Program - Small Business Expression of Interest Form

Please enter your registration details:

*Legal Business Name  
Trading As  
*ABN  
Workers Compensation Policy Number  
*Applicant's First Name  
*Applicant's Last Name  
*Position Title  
*Business Principal's Name  
*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  
*What region are you located  in?  
*Work Phone  
Work Fax  
Mobile  
*Email  
*Preferred method of communication
Phone Email
Fax
*What industry is your business in?
Manufacturing Construction
Retail Consumer Services
Transport Community Services
Agriculture Other

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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