1 ADDITIONAL APPLICATION FORM FOR ADMISSION TO THE POSTGRADUATE CLINICAL PSYCHOLOGY PROGRAM Applicants should note that in order to commence the program they will need to have Provisional Registration status with the Psychology Board of Australia. Further details are available at: Registration requires applicants to disclose the following: Any criminal history An impairment that is likely to detrimentally affect your capacity to practise as a psychologist If your registration in any profession is currently suspended or has been cancelled in Australia or overseas Registration also requires applicants to have met the English Language Registration Standard (IELTS academic level 7). For full details see: Guidelines/Registration-Standards.aspx SECTION A: APPLICANT DETAILS Title Surname Given Names Postal Address (Please notify us of any change of address after submitting your application) Suburb/City State Postcode Country Phone (BH) Phone (Mobile) Date of Birth Male Female If you are currently, or were previously, enrolled at the University of Tasmania, please state your Student Identity Number: Citizenship: Australian Citizen Permanent Resident International Student
2 SECTION B: PROGRAM OF STUDY Intended Study Mode: Full-time Part-time Preferred Program of Study: MPsych(Clin)... MPsych/PhD SECTION C: ACADEMIC QUALIFICATIONS (this program is currently subject to approval by the University Council) Please provide a summary of your qualifications on this form. Certified academic transcripts of degrees and diplomas undertaken, including grades and subjects with a key, should be attached to your online postgraduate study application. N.B. Academic transcripts are not needed for degrees undertaken at UTAS. Title of Degree/Diploma Name of Institution Completion Date Degree Classification e.g. Honours 2A Course Duration Accredited Program of Study Please note: Entry to the Postgraduate Clinical Psychology Program is only open to those applicants who have completed, or will complete, a four year Australian Psychological Society (APS) accredited program of psychology studies. Those applicants who do not hold an APS accredited honours level degree, must have their qualifications assessed by the Australian Psychological Society and provide the assessment report from the Society with this application. Academic Prizes and Awards SECTION D: RESEARCH Please outline any research undertaken during the degrees listed above. If you submitted a thesis, please indicate the title and date of submission.
3 Have you published research or presented research at a conference? Yes No Please give details: SECTION E: RELEVANT EXPERIENCE Please outline your experience relevant to the practice of psychology (this may include any voluntary work). Organisation Brief description of position/duties Period of Work (Dates: From - To) Duration (hours per week)
4 SECTION F: REASONS FOR APPLYING TO THE UTAS CLINICAL PSYCHOLOGY PROGRAM?
5 SECTION G: ACADEMIC REFEREES Please list the names and contact details of your two academic referees. Please ensure that you send your referees the Academic Referees Report Form and ask for the reports to be returned direct to the Division of Psychology by 31 st October Referee Name: Contact No Referee Name: Contact No. SECTION H: INTERVIEWS All applicants should be prepared to attend an interview at the Division of Psychology in Hobart. Interviews are usually conducted towards the end of November. It is expected that all selected domestic applicants will attend this interview. International and domestic applicants who are overseas at this time, and therefore cannot attend the interview in person, may be interviewed by phone or video conference (if available) by prior arrangement. Those applicants selected for interview will be contacted by phone or initially. SECTION I: APPLICANT DECLARATION I declare that the information I have supplied on this form is correct and complete. Signature: Date: Please return this form and any necessary supporting documentation by 31 October 2014 to: Christine de Villeneuve, Program Delivery Officer, Division of Psychology, University of Tasmania, Private Bag 30, Hobart, Tasmania 7001, Australia. Please ensure that you also submit an application for postgraduate study via the University of Tasmania online eapplication system by 31 October Information on the university admissions procedure can be found at: Domestic applicants: International applicants: