Emerson Educational Services - Enrollment Request Form

Registration Request: Australia/New Zealand Courses
Educational Services will contact you to COMPLETE and CONFIRM your enrollment. Be prepared to provide a purchase order number or a valid credit card to process your request. Acceptable credit cards include: Bankcard, Visa, Mastercard and American Express. All cards can be processed in AUD only. AMEX has a 4% surcharge. We value your business and the trust you have placed in Emerson. We take the protection of our customer’s information very seriously. Due to the inherent risks associated with the internet and as part of our ongoing commitment to our customers, we are informing our customer NOT to email their credit card information. There are many risks with sending personal information, especially through the internet. Please feel free to contact us at +61 3 9721 0200 to provide your credit card information or if you have any questions or concerns. * Indicates a required field to enroll Available Courses * * Preferred Course Date Student Name: * First M * Last * Job Title Contact Information: * Phone * Fax * Email * Company Name * Address * City * State/Province * Postal Code * Country As a wholly owned subsidiary of a US company, the products, services and technology that we provide are licensed for Export by the BIS (Bureau of Industry and Security), and as such, we are required to determine the end user, end use and final destination of the products, services and technology. As many of our products contain technology or materials that are controlled, there are limitations on to whom and where the products can be supplied. As such, by determining the final destination, end user and end use, we can carry out the necessary checks to ensure that the supply is with the determined license. We will also screen the end user / end use against a global restricted party list, which is list supported and updated by a number of countries and organizations around the globe, including but not limited to, the DTI in the UK, Japanese Government Gray list for Nuclear and WMD proliferation, Australian Government, UN etc. Nationality is defined by the passport(s) that you hold or could hold.” * Nationality Please list any special dietary requirements: Student Experience Relevant to this Course: Additional Comments: Export Compliance: The acceptance of this enrolment and the fulfillment of any contractual obligations as a consequence of the enrolment is subject to all current applicable import, export control and sanctions, laws, regulations, orders and requirements, including those of the United States where applicable. However, such laws and regulations may be amended from time to time including during the processing of an enrolment. If Emerson Process Management (The Company) should fail to receive any necessary or advisable licenses, authorizations or approvals, even arising from inaction by any relevant government authority, or if any such licenses, authorizations or approvals are denied or revoked, or if there is a change in any applicable laws, regulations, orders or requirements that would prohibit the Company from fulfilling any enrolment, or would in the reasonable judgment of the Company otherwise expose the Company to a risk or liability under such laws, regulations, orders or requirements if it fulfilled the enrolment, the Company shall be relieved without penalty of all obligations with respect to this enrolment. Further enquiries about Courses, please contact: Emerson Process Management – Educational Services, Australia and New Zealand John Atkins Training Manager Phone +61 3 9721 0200, Fax +61 3 9720 6614 email: John.Atkins@Emerson.com

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