SHADRACK SAFETY INSTITUTE COMPANY LTD

SAFETY MATTERS
#16 Siparia Erin Road, Philippine Drive, Duncan Village, San Fernand0.

TEL: 489-2426 /652-9077 E-MAIL: shadracksafetyinstitute@yahoo.com

FORM NO. SSI _________ STUDENT REGISTRATION

(PLEASE PRINT)

1. Student Name:
Surname First Middle

2. Date of Birth: 3. Gender: M F

4. National I.D. No. / Passport No.: 5. Student I.D. No.:
6. Residential Address:
7. Mailing Address: (If Different)
8. E-mail Address: 9.Telephone #: Mobile #:
10. Occupation: 11.Business Phone#:
12. Work Address: Fax:
13. Next of Kin: Telephone:
14. I hereby consent to sharing information with NEBOSH / IOSH in order to complete my registration process .
PROGRAMME:
COURSE TUITION DISCOUNT DURATION

NEBOSH DIPLOMA $30,000 2 YEARS

OFFICAL USE

DATE PAID RECEIPT # AMOUNT BALANCE DUE

PAYMENTS:

There must be at least a fifty percent (50%) down payment or payment plan on any programme being
perused as to ensure your place in classes.

WITHDRAWAL POLICY:

SSI reserves the right to alter its curriculum, cancel courses or change faculty without prior notice when
circumstances warrant. SSI will not be held liable for change in student personal schedule or health. If
you withdraw up to seven (7) days before the program starts (excluding Short Courses), a refund will be
given less a 20% charge of Administration fees. If a participant withdraws within seven (7) days of
commencement of the programme, he/she will incur a 20% administrative charge plus cost of classes
attended.
There is two week period in which refunds will be issued.

CERTIFICATION:

I, the undersigned, hereby certify that the statements made by me in this application are correct to the
best of my knowledge