Enrolment Form

Please complete this form in full.

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Have you completed your LLN Indicator *

Have you completed your LLN Indicator Yes No I have previously completed a similar course

What's This?
We are required to collect a language literacy and numeracy (LLN) indicator prior to enrolling a student. If you have not completed your LLN we cannot proceed with your enrollment. Go to http://www.civilsafety.edu.au/lln/ to complete your LLN.
UNIQUE STUDENT IDENTIFICATION (USI) NUMBER

If you do not have a USI you can create one at www.usi.gov.au or ask for a USI form to allow Civil Safety to create one your behalf. From 1st January 2015, no certificates are able to be printed if a person does not have a USI.
Do you have a USI Number? If No, please go to www.usi.gov.au to create one *

Do you have a USI Number? If No, please go to www.usi.gov.au to create one Yes No
If Yes, please provide your USI Number
Title *

Title Mr Mrs Miss Ms
Given Names - e.g. your given names on your Driver Licence *
Surname Name - e.g. your surname name on your Driver Licence *
Preferred Names
Sign here

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Previous Names?

Do you have previous names such as maiden name, country of origin or indigenous name(s), alias or pseudonym names
If Yes, please include your previous name below *

If Yes, please include your previous name below No Yes
Name Name First Last
Date When Changed Date When Changed / DD / MM YYYY
Date of Birth Date of Birth * / DD / MM YYYY
Your Email Address *
Contact Phone No.
Address - i.e. Your home address. This means the address which you usually live, NOT a temporary address at which you live for work or training Address - i.e. Your home address. This means the address which you usually live, NOT a temporary address at which you live for work or training *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Postal Address - if different to above
Upload a document as proof of your current residency (Phone Bill, Electricity Bill, Bank Statement, etc.)

Attach Files
Upload a photo of your Driver's Licence (front) or other photo ID *

Attach Files

Whats This? Use this function to take a photo of your Driver's Licence (front-side) or select a previous photo of your Driver's Licence from your gallery.
Upload a photo of your Driver's Licence (Back) *

Attach Files

Whats This? Use this function to take a photo of your Citizenship ID or select a previous photo of your Driver's Licence from your gallery.
Upload a photo of your Citizenship ID (Current Green Medicare Card, Current Au/NZ Passport or Birth Certificate)

*this is required for funded training such as CSQ or C3G

Attach Files

Whats This? Use this function to take a photo of your Driver's Licence (rear-side) or select a previous photo of your Driver's Licence from your gallery.
Course/Unit Title *
Civil Safety Location for Training *
Do you have any previous qualifications, units or licences that may be used as RPL? *

What's This? By uploading copies of your previous qualifications, units or licences we can advise if you qualify for a direct credit transfer. This can reduce the cost and time of your training.
Upload a copy of your previous qualification, unit or licence

Attach Files
Upload a copy of your previous qualification, unit or licence

Attach Files
Upload a copy of your previous qualification, unit or licence

Attach Files

Enrolment Form

Enrolment Form

UNIQUE STUDENT IDENTIFICATION (USI) NUMBER

Previous Names?