Application Form Section A – 10634NAT Advanced Diploma of Aboriginal Specialist Trauma Counselling Surname: Name: Gender: Date of Birth: Job Title: Organisation Name: Organisation mailing address: Suburb: State: Postcode: Phone: Mobile: Fax: Email: Mailing address for correspondence (if different): Suburb: State: Postcode: Central Coast LHD Aboriginal Affairs Far West NSW LHD ADHAC Hunter New England LHD Family & Community Services (FaCS) Illawarra Shoalhaven LHD Corrective Services Mid North Coast LHD Department of Education Murrumbidgee LHD Forensic Mental Health Nepean Blue Mountains LHD Housing Northern LHD Interstate Employer Type Employer Type Northern Sydney LHD (NSW Health): (Other): Justice Health South Eastern Sydney LHD Juvenile Justice Western Sydney LHD Ministry of Health Southern LHD Non-Government Sydney Children’s Hospital Sydney LHD Other Government Western LHD NSW Police Western Sydney LHD Private Practitioners St Vincent’s Health Network Please indicate the fee payable for your employer type (Table of costs on course information sheet, page 1): $ Your country of origin: Primary language spoken at home: Please specify access/mobility requirements:
Application Form – Section A 10634NAT Advanced Diploma of Aboriginal Specialist Trauma Counselling Surname: Name: Gender: Date of Birth: Job Title: Organisation Name: Organisation mailing address: Suburb: State: Postcode: Phone: Mobile: Fax: Email: Mailing address for correspondence (if different): Suburb: State: Postcode: Employer Type (NSW Health): Central Coast LHD Far West NSW LHD Hunter New England LHD Illawarra Shoalhaven LHD Mid North Coast LHD Murrumbidgee LHD Nepean Blue Mountains LHD Northern LHD Northern Sydney LHD South Eastern Sydney LHD Western Sydney LHD Southern LHD Sydney Children’s Hospital Sydney LHD Western LHD Western Sydney LHD Employer Type (Other): Aboriginal Affairs ADHAC Family & Community Services (FaCS) Corrective Services Department of Education Forensic Mental Health Housing Interstate Justice Health Juvenile Justice Ministry of Health Non-Government Other Government NSW Police Private Practitioners St Vincent’s Health Network Please indicate the fee payable for your employer type (Table of costs on course information sheet, page 1): $ Your country of origin: Primary language spoken at home: Please specify access/mobility requirements: