Please select on the box which Training Title you want to register:

NEBOSH International General Certificate (IGC) NEBOSH International General Certificate – Distance Learning (IGC) NEBOSH International Certificate in Construction Health and Safety (ICC) NEBOSH International Certificate in Oil and Gas Operational Safety (IOGC) NEBOSH International Certificate in Fire Safety and Risk Management (IFC) NEBOSH International Diploma in Occupational Health and Safety IOSH Managing Safely

Training Dates

Location:

Title: Mr. Mrs. Ms. Professor

Family Name:

Given Name/s:

Date of Birth (dd/mm/yyyy):

Gender: MALE FEMALE

Nationality:

Telephone:

Mobile No.:

Email Address:

Home Address:

Company Name:

Address:

Telephone/Fax No.:

For NEBOSH IGC re-sits IGC 1 IGC2 IGC3

For NEBOSH Diploma re-sits

Unit A Unit B Unit C Unit D

NEBOSH Candidate No. (If you passed any NEBOSH course before)

Date of last exams:

Training Centre where you last sat the IGC exams

For IOSH re-sits Assessment 1 Project Paper

Exam Type Initial Re-Test

NEBOSH & IOSH COURSE ENROLMENT FORM

PLEASE SEND APPLICATION WITH YOUR PAYMENT DETAILS

(PLEASE USE CAPITAL LETTERS THROUGHOUT)

Hope Safe Environment Ltd. Unit 15, Floor 5th, Aqaqia 3/1 Building, Phase 2, Navab-e Safavi Highway, Tehran, Iran Postal Code: 1331685374 Tel: +98 21 55435016,

+98 21 55435146 Fax: +98 21 55435146 Mob: +98 912 8483272 E-mail: Info@hope-se.com, Nebosh@hope-se.com Website: www.hope-se.com

Declaration: I understand that HSE Ltd. and its associated trading companies (and companies, organizations or agents processing data on its behalf) will hold and use personal data supplied by me for administration purposes. These purposes have been notified under the Data Protection Act 1998. The data may also be used to send separate unsolicited mailings containing details of events, new services, products, etc. You have the right to ask HSE Ltd. NOT to send such mailings.

CANDIDATE’S SIGNATURE:

METHODS OF PAYMENT (Please indicate) Full payment must accompany this booking form. Bookings received without payment will be treated as provisional and does not guarantee a seat.

Bank Transfer (RIALs) Cash (USD)

Payments by BANK TRANSFER (in RIALS), please make payable to:

Bank Transfer: Day Bank – Tohid Square Branch-Code. 0143 IBAN NO: IR 3106 6000 0000 2005 6869 7000 A/C Name: HODJAT ARABI

PLEASE READ CAREFULLY:

1. The Client must notify fee verbally or in writing the representatives of International Professional Qualifications of HSE Ltd. if he/she wishes to cancel the registration, change course dates or switch from one course to another. The notifications must be done at least 30 business days in advance before the course starts in order to avoid paying cancellation fee. Cancellation fee equals 50% of the course fee. If customers want to cancel the registration, change course date and switch to another preparatory course they have to pay cancellation fee of 100% of the course fee.

2. Please attach your Passport (Minimum 12 months Validation) copy to this form.

FOR OFFICE USE ONLY

Date Booking No.

Amount paid Invoice No.

Miss Dr. Sir Capitan