ACCREDITED PROGRAMS PTY. LTD.
A.B.N. 72 083 272 128
50 Price Avenue Mount Waverley 3149
P.O. BOX 4049, East Burwood 3151.
DH(98/056)
www.accreditedprograms.com.au
Telephone: (03) 9886 5099
Mobile: 0401 684 875
WELCOME TO ACCREDITED PROGRAMS ( 98/056)
REGISTRATION LETTER
Name
Date: ......./....../......
This letter is to confirm that you have been registered to attend a drink
driver program with Accredited Programs.
The program will be conducted on the following dates and times.
Session 1: ......./......./...... .
6:15 p.m. SHARP --- 10:15 p.m.
Session 2: ......./......./.......
6:15 p.m. SHARP --- 10:15 p.m.
The program will be held at:
CAMBERWELL COMMUNITY CENTRE
33 FAIRHOLM GROVE,
CAMBERWELL (Behind Target, Near Camberwell Station)
**Important**
To complete the program, you will be required to attend both sessions. To ensure efficient running of the program we ask
that you observe the following conditions of attendance.
1. Alcohol and other drugs
Attendance while under the influence of alcohol or other drugs is NOT permitted. It is a requirement that you attend
with a ZERO blood alcohol concentration. You will be breathalysed upon arrival. Participants who behave in an
unruly/disruptive manner will be asked to leave and will be excluded from any further sessions.
2. Smoking
Smoking is not permitted in the building.
3. Lateness
Late arrival cannot be guaranteed entrance to a session. Please try and arrive at least five minutes before the
appointment time. If you are running late, please contact Accredited Programs on 0401 684 875.
4. Missed Sessions
Any session that is missed, for whatever reason, will need to be completed and may delay your completion of the
program. Missing the first session of a program will result in exclusion from the entire program.
5. Warning
Failure to abide by the above conditions may result in exclusion from the program. You may re-book provided the
appropriate fees are paid. Fees are partly refundable if cancellations are made two weeks prior to the program.
6. Completion Certificates
At the completion of the program you will be issued with a Completion Certificate verifying your attendance.
7. Confidentiality
Information you volunteer during the program is strictly confidential and shall not be released to other agencies.
8. What to bring?
Please bring a pen and a snack if desired. Tea/coffee making facilities will be available.
9. Fee
A fee (Inc. GST) is payable as soon as possible or a minimum two weeks prior to attending the program unless
alternative arrangements have been made. Please complete the enclosed registration letter marked PART A and send
with payment. Please refer to the back of PART A for payment details.
LOOK FORWARD TO SEEING YOU THERE.
Mr Peter J. R. Redding
BA (Psych), Dip.S.S, Dip.Hyp, MAPS
Clinical & Educational Supervisor
ACCREDITED PROGRAMS PTY. LTD.
A.B.N. 72 083 272 128
50 Price Avenue Mount Waverley 3149
P.O. BOX 4049, East Burwood 3151.
DH(98/056)
www.accreditedprograms.com.au
Telephone: (03) 9886 5099
Mobile: 0401 684 875
PART A
ACCREDITED DRINK DRIVER EDUCATION PROGRAM (98/056)
REGISTRATION AND ATTENDANCE FORM
PLEASE COMPLETE THIS FORM AS SOON AS POSSIBLE OR A MINIMUM TWO WEEKS PRIOR TO
YOUR ATTENDANCE. FOR FURTHER INFORMATION ON HOW TO PAY PLEASE TURNOVER.
COURSE LOCATION:……………………………………………………..…..COURSE DATE: .……/….…/….…
NAME: …………………………………………………………………………….. Date of Birth:……./……./….…..
Address:………………………………………………………………………….Gender (Circle one):
M
F
………………………………………………………………………………….Postcode:…………………..…………..
Telephone:
Home:…………………………………. Work:…………………………….
Date of Offence: ……./……./…….
Dates of Disqualification:
Blood Alcohol Concentration:……………….gm/100ml (e.g. 0.12%)
From: ……./……../…….. To: ……../……./…….
Type of Licence at Time of Offence (Circle one):
Unlicensed
Learner
Probationary
Full
Total number of Drink Driving Offences ( Within the last ten years ): ………………
Fluency in English (Circle one):
Adequate
Not Adequate
I acknowledge that I have been given a Program Registration Letter informing me of program dates, times, venue and
containing the attendance conditions. I hereby acknowledge sole responsibility for my actions, as required by the
Department of Human Services, should I break any of these conditions.
Enclosed is a cheque/money order (Inc. GST) being payment to attend the drink driver education program.
Signed: ….…………………………..
Dated: ……./……./…….
OFFICE USE ONLY: Date: ……/……/…… Client Number:…………………….
Assessment Required: Yes No Date 1A: ……./……./……. 2A: ..…./……./..….
Program completed: Yes No Date of Missed Session: ……./……../……..State reason: …………….……
Program Leader Signature:………………………………………….
Mr Peter J. R. Redding
BA (Psych), Dip.S.S, Dip.Hyp, MAPS
Clinical & Educational Supervisor
HOW TO PAY
PLEASE COMPLETE THE BACK OF THIS FORM AS SOON AS POSSIBLE OR A MINIMUM TWO WEEKS
PRIOR TO YOUR ATTENDANCE AND SEND WITH PAYMENT.
PAYING BY MAIL
Please complete the back of this form and send it with your cheque or money order payable to:
ACCREDITED PROGRAMS.
OR
Complete your credit card details below and send it with the back of this form completed.
PAYMENT ADDRESS:
ACCREDITED PROGRAMS
P.O. BOX 4049
EAST BURWOOD 3151
PAYING BY PHONE
Please contact ACCREDITED PROGRAMS DIRECT on (03) 9886 5099 with your credit card details.
PAYMENT BY CREDIT CARD
Credit Card Number: __/__/__/__/
Expired Date: __/__/__/__/
Type of Credit Card: BankCard
__/__/__/__/
__/__/__/__/
__/__/__/__/
Amount being paid: $_____________
MasterCard
Visa
Amex
Cardholders Signature:______________________________________
Diners