Select Campus* : Select CampusSydney - Level 2, 14 Railway Parade, Burwood, NSW 2134Adelaide - 62 Gawler Place and/or 19 Young Street, Adelaide, SA 5000

Full Name*:

Gender*: MaleFemaleOther/Not specified

Preferred Name:

Date of Birth*:

Email*:

Birthplace*:

Country of Birth*:

Nationality*:

Passport No*:

Passport Expiry Date*:

Visa Status: Select Visa StatusStudent VisaTourist/VisitorVisa GrantedVisa RefusedWorking HolidayOther

Visa Number:

Visa Expiry Date:

At which office are you going to apply your visa:

Are you of Aboriginal or Torres Strait Islander origin? YesNo

Compulsory for all students enrolling in accredited courses as at 1 January 2015. If you have not yet obtained a USI you can apply for it directly at http://www.usi.gov.au/create-your-USI/ on computer or mobile device. Please note that if you would like to specify your gender as ‘other’ you will need to contact the USI Office for assistance.

Do you have your USI number available now?:

What is USI? | Steps to Create your own USI

Street:

City/Town/Suburb:

State :

Postcode :

Email:

Country:

Home Phone:

Work Phone:

Mobile Phone:

Street*:

City/Town/Suburb*:

State :

Postcode* :

Email*:

Country*:

Home Phone:

Work Phone:

Mobile Phone*:

Name *:

Relationship* :

Address*:

Telephone*:

Mobile*:

Email*:

What is your highest COMPLETED secondary school level? (Tick one box only) :Completed year 12Completed year 11Completed year 10Completed year 9 or equivalentCompleted year 8 or below

Are you still attending secondary school?: YesNo

Which year did you complete that secondary school level?:

Have you SUCCESSFULLY completed any of the following qualifications?: YesNo

If yes please select which qualifications form the below list:
Bachelor Degree or Higher DegreeAdvanced Diploma or AssociateDiploma (or Associate Diploma)Certificate IV (or Advanced Certificate/Technician)Certificate III (or Trade Certificate)Certificate IICertificate ICertificates other than those listed

Is English your First Language? :YesNo

Please Provide evidence of your English language proficiency.IELTSTOEFLPTECAEOther

Score Achieved:

Year Taken:

Listening :

Reading:

Writing:

Speaking:

In order to provide appropriate support services, we invite you to give us information about any disability or mental health issue you may have.

1. Do you consider yourself to have a disability, impairment or long term condition?YesNo

2. If yes, then please indicate the area of disability, impairment or long term condition: (you may indicate more than one area):

Hearing/deaf Medical conditionLearningIntellectualVisionAcquired brain injuryPhysicalMental Illness

3. Do you require special assistance?YesNo

1. Completed all sections of this application form? YesNo

2. Your certified copy of Passport*:

3. Attached/enclosed certified copied of your visa:

4. Attached/enclosed certified copies of your qualifications*:

5. Attached/enclosed certified copies of English language proficiency:

6. Attached/enclosed any other certified documents requested in this application form:

Consultant:

Agency:

Agency Email Address: