Registration Form

Registration is a two part process

Complete your primary registration details below, and you will receive a confirmation email and password
Login and complete additional profile information to search for information, and view reports, on other members of the Ballarat ICT cluster.

Note that all fields proceeded by a red star are compulsory fields.*

Terms and Conditions

I have read and agree to be bound by the Terms and Conditions of registration. I also accept that some details supplied in my registration will be made publicly available on the Ballarat ICT website (the publicly available fields are shown bold in the registration form below. If you would like a hard-copy of the terms and conditions or consent form, please contact us.

Yes, I have read and agree to the Terms & Conditions

Registration Details

Your First Name

Your Last Name

Username

Email Address

Registered Business or Company Name

Primary Contact

Address Line 1

Address Line 2

Suburb

Post Code

Telephone eg: (03 1234 4321)

Facsimile

Mobile Number

Business Website Address (URL)

Do you want your organisation and contact details to be displayed to other registered participants in the Ballarat ICT Directory?

Yes No

Are you interested in participating in future research related to ICT activities in the Ballarat region ?

Yes No

ICT DIRECTORY

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