Western Australia Police Service Leonora Police Station

Rochester StreetLEONORA WA 6438

PH: (08) 90376100 FAX: (08) 90376666

Leonora.police.station@police.wa.gov.au

Prospectors Safety Form

Personal Details

Name __________________________________________ Date of Birth _________________

Address _____________________________________________________________________

Home Phone ______________________________Mobile _____________________________

Vehicle Make/Model ___________________ Colour __________ Registration ___________

Previous Experience ___________________________________________________________

Any Medical Conditions ________________________________________________________

Other Persons in Party _________________________________________________________

(If travelling with others please encourage them to complete a form)

Equipment

Sat Phone: Yes/No. Number ___________________________________________________

EPIRB: Yes/No. PLB Yes/No. GPS: Yes/No.

Location

Planned Destination _______________________________________________________________

Co-ordinates if known _____________________________________________________________

Tenement Number if applicable _____________________________________________________

Duration of Stay __________________________________________________________________

Emergency Contact

Emergency Contact Name ________________________ Relationship ______________________

Emergency Contact Address ________________________________________________________

Emergency Contact Number/s _______________________________________________________

Please complete and return to Leonora Police Station, Leonora Shire Office or DMP Leonora.