TO SAFECITY TRAINING ACADEMY

I wish to enrol in the following instructor course (s)

ACT Certificate IV in Security Industry Firearms Instructor Course #10832ACT $1100

ACT Defensive Tactics, Baton and Handcuffs Instructor (Graduates will achieve qualifications in the Certficate IV in Assessment and Workplace Training #BSZ40198 and Employ Batons and Handcuffs #15572ACT) $1400

ACT Certificate IV Security Industry Firearms Instructor Course + Defensive Tactics, Baton and Handcuffs Instructor $1800

Certificate IV in Assessment and Workplace Training #BSZ40198 NSW Class 2D Licence qualifications $800, This course does not qualify you to conduct batons or firearms courses.

Senior First Aid Course $100 (includes firearms gun shot wounds and needle stick injuries)

Senior First Aid Instructor $400 (includes firearms gun shot wounds and needle stick injuries)

I have enclosed my cheque/money order for the amount of  $____________________ being payment in full for my course fees.

OR I wish to pay  $ __________ by credit card.(circle)  VISA   MASTERCARD    BANKCARD

Card Number _________________________________ Expiry ____________________

Name on the card _________________________ Signature _________________________
 

Upon receipt of my course fees, you will confirm my enrolment and send me the course manuals.
 

Signature_______________________________ Date______________
 

APPLICATION FORM PART A
 

Preferred First _____________________________________
 

Name_____________________________Birth date____________ Sex M F
 

Please write your full name as it appears on your licence.

Full Name ________________________________________________________________

Security Licence #____________________________________ Expiry date_____________

Instructor Licence #___________________________________ Expiry date_____________

Firearms Licence #__________________________________________________________

Firearms Licence Category__________________________Expiry date_________________

Postal Address _____________________________________________________________

City_______________________________________State__________Postal Code________

Residential Address__________________________________________________________

City_______________________________________State__________Postal Code________

Contact home phone number ( )__________________________________________________

Contact work phone number ( )__________________________________________________

Contact fax number hm/wk ( )___________________________________________________

Occupation_________________________________________________________________

Name & Address of Employer___________________________________________________

__________________________________________________________________________

City______________________________________State__________Postal Code__________

If you have never attended a Safecity course, have you successfully completed a...

• Firearms Instructor Course?_______ (please attach copy of certificate)

• Defensive Tactics Baton and Handcuff Course?_______ (please attach copy of certificate)

•Senior First Aid Certification? ____________ (please attach copy of certificate)
 

APPLICATION FORM PART B - PERSONAL INFORMATION

Name ___________________________ Surname _______________________________

1. During this course you will participate in role plays which may involve:
a. physical exertion.
b. body contact with other participants and the lecturers
c. some offensive language and simulated threatening behaviour
d. the use of weaponless techniques (holds, strikes) and batons and handcuffs
e. the use of firearms

Do you clearly understand the meaning of points 1(abcde)?_______________

2. Do you suffer from any physical or mental disability that may affect your participation in these

instructor courses? __________________

3. Are you pregnant or attempting to become pregnant?______________________

4. Have you ever been charged with a criminal offence (other than minor traffic offences) in Australia or overseas?_____________

To the Directors of Safecity Training Academy, I fully understand the meaning of points 1,2,3,4 in this application form. I have answered all questions truthfully to the best of my knowledge.
 

Signature_______________________________ Date______________
 

MEDICAL STATEMENT PART A Part of your training may involve vigorous physical exercise, firearms instruction and baton and handcuffs instruction. You may be exposed to loud noise, air and noise pollution.

Please read this carefully, complete the form IN CLEAR HANDWRITING STYLE before signing. Please discuss any questions you may have with your Family Doctor. This information will be treated as confidential.

NAME________________________SURNAME_____________________DOB_______

Please answer the following questions on your past or present medical history with a YES or NO, if you are not sure answer YES. Your Doctor will explain the question thoroughly. A YES response to a question does not necessarily disqualify you from the course.

Could you be pregnant or are you attempting to become pregnant? ________

Do you regularly take prescription or other medications? ________

Are you over 45 years of age and one of the following applies: Currently smoke, have a high cholesterol level, have a family history of heart attack? ________

Have you ever had or currently have: Asthma or wheezing with breathing or with exercise?_______

Any form of lung disease? __________

History of chest surgery? __________

Claustrophobia or agoraphobia? __________

Behavioural health problems? __________

Epilepsy seizures, convulsions? __________

History of blackouts or fainting? __________

History of diabetes? __________

History of arm or legs problems? __________

Inability to perform moderate exercise? __________

History of high blood pressure? __________

History of heart problems? __________

History of ear disease or damage to the ear? __________

MEDICAL STATEMENT PART B

Part of your training may involve vigorous physical exercise, firearms instruction and baton and handcuffs instruction. You may be exposed to loud noise, air and noise pollution.

Please read this carefully, complete the form IN CLEAR HANDWRITING STYLE before signing. Please discuss any questions you may have with your Family Doctor. This information will be treated as confidential.

NAME__________________________SURNAME_____________________DOB__________

Please answer the following questions on your past or present medical history with a YES or NO, if you are not sure answer YES. Your Doctor will explain the question thoroughly. A positive response to a question does not necessarily disqualify you from the course.

Have you ever had or do you currently have:

History of bleeding or other blood disorders? ________

History of any type of hernia? ________

History of drug or alcohol abuse? ________

Problems of any type with vision? ________

Are you colour blind? ________

Is there anything else about your health we should know? _______

If you have answered yes to any of the above questions, please provide details. I hereby certify that the information I have provided about my medical history is accurate to the best of my knowledge.

Signature____________________________________ Date________________________

ACKNOWLEDGEMENT OF ADVICE AND CONFIRMATION OF ASSUMPTION OF RISK Please read this carefully, complete the form IN CLEAR HANDWRITING STYLE and initial each paragraph before signing. This form must be signed before a witness over the age of 18.

I (Name and Surname)_____________________________________,

(date of birth) _____/____/______

of (residential)_______________________________________________________________

in the ACT, do solemnly and sincerely declare as follows:

I hold a _______________________________licence number_________________________

The licence is valid until _________________.

There are no restrictions that prevent my use or possession of firearms, batons and handcuffs. I acknowledge that I am aware of the inherent risks of undertaking the ACT Security Industry Firearms Instructor Course and/or the Weaponless Tactics, Baton and Handcuff Instructor Course with Safecity.

In particular, I acknowledge that I have been advised of the following:

1. That part of my course may involve physical exertion and body contact with my instructors and other trainees.
2. That part of my course may involve the use of firearms and equipment capable of causing injury or death to myself and other persons.
3. That part of my course may involve loading, firing and unloading firearms both in good and poor visibility conditions.
4. That I must not at any time during the course assume a firearm is unloaded unless I have personally inspected it by opening the action and removing the magazine in case of a semiautomatic pistol, by opening the cylinder and by removing all cartridges in case of a revolver, and by opening the action and removing all ammunition in case of a shotgun. AND by showing the firearm to my Instructor.
5. That part of my course may involve using batons and handcuffs both in good and poor visibility conditions.
6. That if I am found to be intoxicated during the course I will be dismissed from the course.
7. I further acknowledge that my attendance to the course is at the discretion of the Course Director and that he or she may dismiss me from the class if my behaviour, attitude or actions are considered dangerous, inappropriate or distracting to other candidates.
8. I further acknowledge that I am aware of the risks associated with the ACT Security Industry Firearms Instructor Course and the Weaponless Tactics, Baton and Handcuff Instructor Course conducted by Safecity Services Pty. Ltd. and I still wish to undertake the course with Safecity Services Pty. Ltd and its instructors, and hereby release and hold harmless, Safecity Services Pty. Ltd, its proprietors and all persons involved with my training, from any suit, demand or claim arising as a consequence of death or injury received by me during my participation in the said course.
9. I further acknowledge that this document may be relied upon in any proceedings instituted in any Court by me or my heirs, executors and assigns.
    

    

   ___________________________________           ______________________________
   Signature of applicant                                                Signature of witness

   ______________________                                     _______________________
   Date                                                                         Date
    
    
   
   

   
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