Registration FormRequest for Access to the
Local Government Environmental Health Resources
Website
1 Applicant Details
Name of user / contact person
Organisation (eg. local
government name)
Work Phone No.
Email address of user / contact
person
Generic* email address to which
updated passwords can be sent
* Local governments are required to nominate a generic email account to which updated passwords can be sent for
access to the Local Government Environmental Health Resources Website. This will assist when a contact person
changes such as leave, acting arrangements, staff turnover etc. Applications not from Local Governments should
provide supporting evidence as to why access should be allowed (ie university EH course coordinator)
2 Declaration
I understand that access to this site is on the following conditions and that access may be withdrawn if
any of the conditions are breached

The username & password are kept secure

The username and password are only disclosed to relevant staff within your organisation

That all staff distributed the username and password details are directed to not further distribute
the username or password
Signed
Date
3 Submission
Send completed form to:
Systems Management Officer
PH Regulation System Manager
Health Protection
PO Box 2368
Fortitude Valley BC QLD 4006
EHOLG@health.qld.gov.au
Office Use Only – PHRSM
Documentation checked:
Yes
Signature and Date: