Please enable JavaScript in your browser to complete this form.APPLICANT DETAILSLayoutFirst Name *Last NamePreferred Address (will be published on the AIDGC website) *LayoutState *Post Code *Postal Address (if different to above)Layout (copy)StatePost CodeEmployer *Position *Telephone – Business *Telephone – Home (in case your employment changes) *Telephone – Mobile *Email *I enclose the following supporting documentationEvidence Of QualificationsEvidence of Relevant Industrial ExperienceI Undertake to Supply Supporting Documentation When Requested by the Examination PanelNOMINATED SUPERVISOR For supervised examSupervisor NameSupervisor EmailAddressAddress Line 1Address Line 2City--- Select state ---New South WalesVictoriaQueenslandWestern AustraliaSouth AustraliaTasmaniaAustralia Capital TerritoryNorthern TerritoryState / TerritoryPostal--- Select country ---AustraliaCountryDate / TimeDateTimeMembership Grade Applied ForConsultantMember to Be Examined forA - Regulations & Risk Assessment All candidates must undertake Part A Assessment on regulations and risk assessment (Only Once) Untick if previously assessed $150.00B - Group 1 LPG & Class 2 $100.00C - Group 2 Class 3 & Class 4 $100.00D - Group 3 Class 5.1 & 5.2 $50.00E - Group 4 Class 6.1, Class 8 & Class 9 $50.00F - Group 5 Transport $100.00Note : Members may choose to undertake assessment in any or all groups. I hereby apply to become a member of the Australasian Institute of Dangerous Goods Consultants Inc in the grade of Membership nominated above. In the event of my admission, I agree to be bound by the Rules, By-Laws, Code of Ethics and Code of Conduct of the Institute and pay any membership fees, for the time being in force.I have not been formally required to justify my conduct to any professional association or regulatory authority except as follows.Upload Signature Click or drag a file to this area to upload. Applications SignatureDate / Time *DateTimeUpload supporting Documents Click or drag files to this area to upload. You can upload up to 6 files. Submit