Part Appendix 3 - Statement of Commitment to - Safety, Rehabilitation and Compensation Act 1988 - section 34S - Approval of Form of Application for Renewal of Approval as a Rehabilitation Program Provider (Workplace Rehabilitation Provider) (30/10/2009) - Appendix 3 - Statement of Commitment to the Code of Conduct for Workplace Rehabilitation Providers

Appendix 3 - Statement of Commitment to the Code of Conduct for Workplace Rehabilitation Providers

I/We have read and agree to conform to the Code of Conduct for Workplace Rehabilitation Providers if approved for renewal as a workplace rehabilitation provider.

I/We understand and are aware that any breach of the Code of Conduct for Workplace Rehabilitation Providers may nullify any renewal application or further Instrument of Approval issued by the workers’ compensation authority in the event the renewal application is approved.

To be signed by the person/s who is authorised to sign this application on behalf of the organisation seeking renewal of approval as a workplace rehabilitation provider.

Organisation Name:_____________________________________________________________

Name and Title of authorised signatory:

Signature of authorised signatory:

_________________________________________Date:___________________

Name and Title of authorised signatory:

_______________________________________________________________________

Signature of authorised signatory:

_________________________________________Date:___________________

Appendix 3 - Statement of Commitment to Appendix 3 - Statement of Commitment to the Code of Conduct for Workplace Rehabilitation Providers

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