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| 1a) Family Name (Surname) |
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| 1b) Last Name: |
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| 2) Date of Birth (Day/Month/Year) |
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| 3) Sex (Tick ONE Box only) |
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| 4) What is the address of your usual residence? (Address Location - Suburb, Locality or Town, Postcode) |
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| 5) What is your postal address? |
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| 7) What is your contact details? (Telephone (home), telephone (work), mobile and email) |
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| 6) In which country were you born? |
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| 8) Do you speak a language other than English at home? (If no please specify. If yes goto Question 9) |
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| 9) How well do you speak English? |
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| 10) Are you of Aboriginal or Torres Strait Islander origin? (For persons of both Aborginal and Torres Strait Islander origin, mark both 'Yes' boxes |
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| 11) Do you consider yourself to have a disability, impairment or long-term condition? |
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| 12) If YES, then please indicate the areas of disability, impairment or long-term condition: (You may indicate more than one area.) |
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| 13) What is your highest COMPLETED school level? (Tick ONE box only.) |
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| 14) In which YEAR did you complete that school level? |
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| 15) Are you still attending secondary school? |
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| 16) Have you SUCCESSFULLY completed any of the following qualifications? |
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| 17) If YES, then tick ANY applicable boxes. |
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| 18) Of the following categories, which BEST describes your current employment status? (Tick ONE box only.) |
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| 19) Summary of Work Experience (Current Position Held, Industry) |
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| Previous Work Experiene 1 (period of employment (start with most recent), position, name of organisation and Industry and outline your key activities (in point form)) |
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| Previous Work Experiene 2 |
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| Previous Work Experiene 3 |
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| Previous Work Experiene 4 |
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| Total years of work experience (years) |
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| Total years of managerial/professional experience (years) |
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| 20) Of the following categories, which BEST describes your main reason for undertaking this course/traineeship/apprenticeship? (Tick ONE box only.) |
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| Please select a course you are interest in attending: |
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| Accident Investigation |
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| Just Culture |
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| Regulatory Oversight & Governance |
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| 21) Additional comments/info |
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