CONTACT DETAILS:

NAME IN FULL:~ ________________________________________________________________________

POSTAL ADDRESS:~ ____________________________________________________________________

____________________________________________________________________

STATE/COUNTRY:~ ______________________________________________POST CODE:~ __________

TELEPHONE NUMBER:~ _________________________________________________________________

DETAILS OF TRAINEE IF DIFFERENT FROM ABOVE:

NAME IN FULL:~ ________________________________________________________________________

POSTAL ADDRESS:~ _____________________________________________________________________

________________________________________________________________________________________

STATE/COUNTRY:~ __________________________________________ POST CODE:~ ______________

TELEPHONE NO:~ _______________________________________________________________________

AGE OF TRAINEE: (MUST BE 18 YEARS OR OVER) __________________________________________

I CONFIRM THAT THE TRAINEE APPLICANT IS IN GOOD HEALTH AND IS NOT KNOWN TO SUFFER

 FROM ANY PHYSICAL OR MENTAL CONDITION WHICH MAY RESULT IN ILLNESS, INJURY, 

 OR ACCIDENT, TO THEMSELVES OR OTHERS WHILST TAKING PART IN THIS COURSE.

I WISH TO APPLY FOR:

I ENCLOSE PAYMENT IN FULL TO THE VALUE OF $___________________ BY CHEQUE,

 OR PLEASE DEBIT MY BANKCARD/MASTER CARD/VISA CARD

NO_________/____________/_____________/_____________EXPIRY DATE:_____/______

$________________________ SIGNED_____________________(CARD HOLDER)

PLEASE INDICATE FIRST AND SECOND CHOICE OF DATES: FOR COURSE

(It is advisable to check availability and to confirm booking by telephone)

1^ST~_________/_________/________ 2^ND_________/_________/_________

FOR FURTHER INFORMATION OR ASSISTANCE, PLEASE CONTACT THE PEMBERTON TRAMWAY Co