Skills Canberra

Application for Extract of ACT Record

Instructions for completion

Complete this form to apply for an extract of an Australian Apprenticeship training contract partially completed in the ACT.
Forms can be submitted by:
Email: skills@act.gov.au
Mail: GPO Box 158, Canberra ACT 2601

Section 1 - Apprentice details

Australian Apprentice number 5925672 Date of birth 25/8/1987

Name Jess Harris
Home phone Mobile phone 0415920005
Email address flawlessjess@hotmail.com
Home address 91 Gibbs street Rockdale NSW

Section 2 - Former apprenticeship details

Qualification code and name CPC32420 - Certificate III in Plumbing

Former employer trading name HYDRO TECH PLUMBING & DESIGN SERVICES PTY LTD
Registered training organisation 0101 - Canberra Institute of Technology

Section 3 - Forwarding details

Please enter each email address you would like the extract sent

Email address 1 youngv2@sarinarusso.com.au

Email address 2 flawlessjess@gmail.com
Email address 3

Section 4 – Declaration and Australian Apprentice signature

I declare the information provided in this form is true, correct and complete.

Signature Date signed

Electronic signatures will be accepted.

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