Training endorsement renewal "*" indicates required fields Step 1 of 5 - Applicant Details 20% Applicant detailsName of contact person* First Last Position/Job title*This field is hidden when viewing the formCompany name*Company name*Please selectAustralian Institute of Professional CounsellorsClinical Supervision ServicesEmbrace EmpowermentFamily & Relationship Services AustraliaGreatfulness Group Pty LtdHuman ConnectionsIFYS ltdKaruna Hospice ServiceMental Health AcademyMindful Life WellnessOnline Courses AustraliaOptimal Health GroupProd Training OrgSupervision Training ServicesWex Group Pty LtdABN*Phone*Email* Company address* Street Address Address Line 2 City/Suburb State / Province / Region Post code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Provider website Are you seeking to renew a Community Work Australia endorsed activity or activities?* Yes No Sorry, you cannot proceed further based on this selection. To apply for a new CPD endorsement please fill out the the CPD endorsement application form here.Previous endorsement ID* Training activity detailsName of activity (as endorsed by Community Work Australia)*Are there any changes to the activity?*YesNoPlease indicate changes to the activity and use the upload section to submit documents detailing these changes.* Name of activity Delivery mode Duration Program content Trainer/Trainers Target Audience Other significant changes No change Select AllUpdated name of activity (as you would like it to appear on Community Work Australia’s website)*Mode of delivery* On campus (classes) Online Blended Duration (if online please estimate)*Target Audience*Please provide a description of the activity and its purpose* UploadsPlease upload: CV with details of the qualifications and experience of facilitator/ presenters Program outline Optional: Marketing material such as flyers, images etc that could be used in Community Work Australia's promotion of your CPD File upload Drop files here or Select files Accepted file types: jpg, jpeg, png, gif, doc, docx, pdf, Max. file size: 20 MB. DeclarationConsent*I declare that: (a) The information I have supplied on this form and any attachments is complete and correct. (b) I have read and understood the information that is relevant to this application. (c) I will tell Community Work Australia of any changes to my circumstances (e.g. address) which may occur while my application is being processed. (d) I authorise Community Work Australia to make any enquiries necessary to assist in this assessment and to use any information supplied in this application for that purpose. Please tick the box to signify that you accept this declaration. I agree to the privacy policy. PaymentYou will have received an invoice from Community Work Australia for your CPD endorsement renewal. You must pay this in order for your application to be processed.Payment Option* I have already paid the invoice. I have NOT paid the invoice, but will pay it. I have NOT received an invoice. Community Work Australia Invoice Number*
