About Safe Work Australia

SafetyAmbassadorRegistrationForm

To become a 2011 national Safe Work Australia Week Safety Ambassador, please complete the registration form below. You will receive automatic confirmation once your form has been submitted.

Before registering, please make sure you understand the role of Safety Ambassador by reading the Safety Ambassador Information sheet.

Note: only one person from each organisation will be accepted as a Safety Ambassador. However, multiple people may apply if you are part of a national organisation with various locations across Australia.

Safety Ambassador details

First name (Required)

Last name (Required)

Email address (Required)

Phone number

Mobile number

Postal address 1 (Required)

Postal address 2

Suburb (Required)

State or territory (Required)

Postcode (Required)

Industry (Required)

Safety quote (Required)
Why is workplace health and safety important to you/ your company? 100 words maximum

Are you registering to become a Safety Ambassador as:
(Required)
an individual
for my company - please complete your company details below

Disclosure (Required)
I provide Safe Work Australia with permission to publish my name, my company name (if applicable) and my Safety quote on the Safe Work Australia website and in other Safe Work Australia communication materials.