Rocklands Drive, TiwiNT
Postal Address:PO Box 41326 Casuarina NT 0811
Tel: +61 8 8922 6929
Email:Website:
MIMMS Commander Course:18-20 November2014
Expression of Interest
8th Floor NCCTRC Training Rooms - RoyalDarwinHospital, Rocklands DriveTiwiNT 0810
Semester Two - NTG DoH Staff: *$655 p.p. incl. GST / Non NTG DoH Staff: *$975p.p. incl. GST
Registrations close: 06 October 2014
SECTION 1: COURSE APPLICATION PROCESS
  1. Lodge completed expression of interest form with NCCTRC Administration Office via email by registration closing date.
  2. The applicant is responsible for notifying their supervisor and ensuring correct rostering procedures are followed.
  3. Take no further action until advised if your application has been successful.
  4. All applicants will be notified at close of registration if their application has been approved / unapproved.
  5. Approved applicants will be sent an acceptance letter with further courses details via email.
  6. Proof of payment must be provided to the NCCTRC Education and Training Team within five (5) working days of receiving acceptance letter.
(Please note completion of an expression of interest does not guarantee a position on this course)
SECTION 2: APPLICANT DETAILS *Mandatory Fields– incomplete enrolment will delay application process.
*Last Name:
/ *First Name:
*Mailing Address:
*AGS Number or PMKey(NTG DoH / ADF Members):
/ *Mobile Number:
*E-mail address:
*Position title: (eg: RN / MO) / *Classification: (eg: N5 / RMO)
*Employer: (eg: DoH / ADF) / *Division / Branch / Service:
*Work location: / Supervisor name: / Supervisor notified
Dietary requirements: / Vegetarian  / Gluten Free  / Halal  / Other 
Please note availability of the above selection is dependent on the caterer. You will be advised if any special dietary requests are unavailable.
Do you have a disability? This is to ensure suitability of venue only. Yes / No If yes please state:
Is English your first language? Yes  / No  If no, please state:
Were you born in Australia? Yes / No
Are you of Aboriginal or Torres Strait Islander origin? / Aboriginal
Yes / Torres Strait Islander
Yes  / Both
Yes  / Not Aboriginal / Torres Strait Islander
No 
Please refer to page 2 for payment options
SECTION 3: Payment – Please Choose ONE of Options 1 / 2 / 3
Option 1:Personal Payment to Receiver of Territory Monies (RTM)
Direct payment to RTM Ground Floor, RoyalDarwinHospital
Credit Card Payment via phone. Ph: 08 8922 8189
Please provide the RTM with the following information:
  • Participant’s name
  • Approval Received from NCCTRC
  • Course title: MIMMS Commander Course
  • Cost of course Semester Two: *$655 p.p. incl. GST (NTG DoH) / *$975 p.p. incl. GST (non NTG DoH)
*prices and availability of courses are subject to change.
  • Cost code: 709641
  • Standard classification: 371919 - Northern Territory Government RDH Staff | 131999 All External Staff
  • Tax code: S10

Option 2: NTG Department of Health (DoH) work unit to cover costs (Journal Transfer / Ledger Transfer)
Delegated Officer to complete as perHRFinancial Delegations
Name: / Position:
Work location: / Phone number:
Cost Centre Code: __ __ - ______- ______/ Tax code:
Approved / Not approved Signature: / Date: / /
Option 3: Non NTG Department of Health Participants - External Work Unit to cover costs – Tax Invoice
Please complete the following details so that a tax invoice can be generated and sent to your organisation for payment:
(Do not complete if you have selected Option 1 or Option 2)
Organisation Name (in full):
Work Unit Name (in full):
Contact Name: / Contact phone number:
Contact email: / Purchase order #
Postal Address:
Town / Suburb: / State: / Post Code:
Proof of payment includes:
  • Receipt from Receiver of Territory Monies (RTM)
  • Enrolment form signed by supervisor and delegated officer with cost code details
  • Purchase order from your organisation (External Work Unit)

CANCELLATION POLICY (APPLICANT): All notifications to withdraw from courses should be done in writing, however a cancellation fee may occur if a participant withdraws within 2 weeks prior to a course. If a participant fails to attend a course without prior notice, the course fee will be forfeited, unless under extreme circumstances.
I have read and understood this application, and have completed all mandatory fields.
Applicant Signature: Date: / /
OFFICE USE ONLY:
Date Received: / Data base entry:
Approved: / Waitlist:

2014 Training Calendar and Course Handbook available on our Website:

Page 1 of 2