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Name
of student:
Yr & Homeroom
Name of company or organization for Work
Placement
Industry type:
Street address:
Postal
address:
(if different from above)
Telephone:
Fax:
Mobile:
Email:
Contact person: ( Mr. or Ms)
First name: Surname:
Title of contact person:
Supervising person ( Mr. /Mrs./Ms)
First name: Surname:
(if
different from above)
Title
of supervising person:
DATES OF WORK PLACEMENT:
From to
HOURS (IF KNOWN):
From
to
Are
you doing Industry and Enterprise studies (Circle your response) Yes/No
If
yes, name of teacher of Industry and Enterprise class:
Are you doing a VET or VCAL Course? (Circle your response
) VET VCAL
NO
If you are doing VET or VCAL , name the certificate e.g.
Certificate II in Building and Construction
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