| Firstname: | First name
required |
| Middle name#1: | Middle Name 1
|
| Middle name#2: | Middle Name 2
|
| Surname: | Surname
required |
| Date of Birth: | Date of Birth
required |
| Home Phone: | Home Phone Number
|
| Address: | Applicant Address
required |
| Mobile: | Mobile phone Number
required |
| Email: | Email Address
required |
| Drivers Licence: | Drivers License
required |
| Company: | Company Name
required |
| Company Phone: | Company Phone number
required |
| MSIC Number: | MSIC Number
|
| MSIC expiry date: | MSIC Expiry Date
|
| Payment: | Enter receipt number.
required |
| Agreement: | Agreement to be bound by Port Standards and Procedures
By completing this induction:
* I agree to carry and display valid Access/Induction Cards and display them at all times while I am in the Port of Broome including any land or infrastructure that is owned, occupied or controlled by the KPA. For Access Cards, I agree to display my valid Maritime Security Induction Card whilst in the Maritime Security Zone at the Port of Broome
* I acknowledge that I have had the opportunity to read the Kimberley Ports Authority Port Standards and Procedures (Broome Port) (Port Standards and Procedures)
* I acknowledge that I can access and obtain a copy of the Port Standards and Procedures from the KPA website www.kimberleyports.wa.gov.au or by requesting a copy from the KPA
* I agree that the KPA may amend the Port Standards and Procedures from time to time and I am responsible for checking on and informing myself about any amendments; and
* I agree that I am irrevocably bound by the Port Stands and Procedures (as amended from time to time).
Acceptance Required:
required |
| | |