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					                          Activity Title:  Introduction to Emergency Risk Management -
                                           Flexible Delivery
                          Activity Number: 2009.98
                          OFFICE USE ONLY
                          Tutor:
                          CD-ROM sent:
                          Guide sent:

    A flexible delivery approach provides greater access to emergency management
                             training for Western Australians.
It is important for nominees to complete all parts of the nomination form to assist with
        communication for nominations, assessment and information exchange.

SECTION A

Given Names:                                                     Email:

Surname                                                          Date of Birth:              /   /


SECTION B
Title
     Mr                 Mrs              Ms               Miss                    Other:


Organisation                                                     Position Held


Business Address

Suburb                                      Postcode
State

Business Phone:                                                  Mobile Phone:

Home Phone:                                                      Fax Number:



Applicant’s Signature                                                                Date:           /      /




                                                       Checklist
          Before submitting this form to the appropriate office, please check that you have:
          Completed all of the required sections of this form, especially your current email and fax
          number.
          Fax this form to FESA on fax number: 08 9323 9462.



FESA, FESA HOUSE, 480 HAY STREET, PERTH                                   PHONE: 08 9323 9336            FAX: 08 9323 946

				
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Description: ① Before submitting this form to the appropriate office, please ...