Application for password creation for the Kimberley Aboriginal Medical Services' Council - Chronic Disease Resource

To: Co-ordinator - Population Health Unit - Kimberley Aboriginal Medical Services' Council

PO Box 1377 Broome 6725 • PH:(08) 91936043 Fax:(08)91922500

We request a password to access the KAMSC Chronic Disease Resource which is located on your website. We agree to uphold copyright ownership in regards KAMSC copyrighted documents and all other organizational copyrights which can be found on this site.

*Service Name

Contact details:

*Postal Address

*Phone

*Fax

*Applicant name: _____________________________________

(CEO/Chairperson)

*Signature:__________________________________________ *Date: _______________________

(*Essential information)

________________________________________________________________________________

Office use only:

Password application: Approved/Not Approved

Your password is:

KAMSC CEO/delegate:

Name:

Signature:

Date: