A.B.N. 85 123 406 039 212 Hoddle St, Abbotsford Victoria 3067, Australia Postal Address: PO Box 375, Abbotsford Victoria 3067, Australia Tel 61 3 9417 4777, Fax 61 3 9417 4787 Web www.imperial.edu.au Email info@imperial.edu.au Please tick the course(s) you wish to enrol in Application for Enrolment VET FEE-HELP Faculty of Information and Communications Technology ICT50415 Diploma of Information Technology Networking ICT60215 Advanced Diploma of Network Security Faculty of Telecommunication Engineering ICT50210 Diploma of Telecommunications Network Engineering ICT80415 Graduate Diploma of Telecommunications Network Engineering Faculty of Business and Management BSB50215 Diploma of Business BSB61015 Advanced Diploma of Leadership and Management Faculty of Marketing BSB51215 Diploma of Marketing Faculty of Hospitality Management SIT50313 Diploma of Hospitality ICT60210 Advanced Diploma of Telecommunications Network Engineering BSB51915 Diploma of Leadership and Management BSB60515 Advanced Diploma of Marketing SIT60313 Advanced Diploma of Hospitality Preferred Course Start Date: / / On Campus Online/ Distance Personal Details Given Name: (Legal Given name) Surname: (Legal Family name) Date of Birth: / / Gender: Male Female Town of Birth: Phone (home): Email Address: Usual Residence Country of Birth: Mobile: Postal Address, (if different to usual residence) Building/ Property Name:... Flat/Unit Number:... Street No:... Building/ Property Name:... Flat/Unit Number:... Street No:... Street Name:... Suburb, Locality or Town:... State/Territory:...Postcode:... Street Name:... PO box or roadside delivery box :... Suburb, Locality or Town:... State/Territory:...Postcode:... Page 1 of 5
Emergency Contact Details Name: Phone Number Address: Relationship to Applicant: Citizenship (tick one) Australian Citizen Holder of a Temporary Protection Visa East Timorese asylum seeker Holder of Permanent Resident Visa Holder of Special Category Visa (New Zealand sub-class 444) Language and Cultural Diversity In which country were you born? Australia Other- please specify:... Do you speak a language other than English at home? No Yes Please specify: How well do you SPEAK English? Very Well Well Not Well Not at All How well do you READ English? Very Well Well Not Well Not at All How well do you WRITE English? Very Well Well Not Well Not at All Are you of Aboriginal or Torres Strait Islander origin? No Yes, Aboriginal Yes, Torres Strait Islander Disability Do you consider yourself to have a disability, impairment or long-term condition? No Yes (If Yes, please specify the areas of disability, impairment or long-term condition. You may indicate more than one area. Please attach documentation describing your disability, impairment or long-term condition in more detail.) Hearing/Deaf Intellectual Mental Illness Medical Condition Physical Learning Vision Acquired Brain Impairment Others: Schooling Are you still attending Secondary School? No Yes What is your Highest COMPLETED school level? (Tick ONE box only) Completed Year 12 Completed Year 11 Completed Year 10 Completed Year 9 or Equivalent Completed Year 8 or Lower Did not go to High School In which YEAR did you complete the above school level? Name of school: Country / State: Page 2 of 5
Previous Qualification(s) (Tick the appropriate box, if you have completed any of the following qualifications in Australia or hold an overseas qualification which is assessed by relevant assessing authority in Australia as equivalent to Australian Qualification) Bachelor Degree of Higher Degree Associate Degree Advanced Diploma Current Employment Details Full-time employee Part-time employee Not employed not seeking employment Employed- unpaid worker in a family business Study Reason To get a job To develop my existing business To start my own business To try for a different career To get a better job or promotion Numeracy and Literacy Level, Credit Transfer and RPL Diploma(or associate Diploma) Certificate IV (Adv Certificate /Technician) Certificate III (or Trade Certificate) Overseas qualification Certificate II Certificate I Certificates other than the above None Employer Self Employed - not employing others Unemployed seeking part -time employment Unemployed seeking Full -time employment It was a requirement of my job I wanted extra skills for my job To get into another course of study For personal interests or self development Other reasons Do you require any language, literacy or numeracy assistance? YES NO Are you seeking Credit Transfer YES NO Recognition of Prior Learning? YES NO If YES, Application for Credit Transfer/Recognition of Prior Learning along with relevant supporting documents must accompany this application form. Victorian Student Number (VSN) Victorian Student Number (VSN) Have you attended any Victorian school since 2009 or done any training with a vocational education and training (VET) registered training organisation or an Adult and Community Education provider in Victoria since 2011? No- I have not attended a Victorian school since 2009 or a TAFE or other VET training provider since the beginning of 2011 Yes- I have attended a Victorian school since 2009. Please specify the most recent Victorian school attended:... And / or Yes- I have participated in training at a TAFE or other training organisation since the beginning of 2011 List the most recent training organisations with which you have participated in training in Victoria since 2011 (List up to 3 training organisations) 1... 2....... 3... Unique Identifier Number (USI) Page 3 of 5
All students studying nationally recognised training in Australia from 1 January 2015 will be required to have a Unique student Identifier (USI). A USI is an account (or reference number) made up of numbers and letters. The USI will allow students online access to their training records and results (transcript) through their online USI Account USI No: (Please attach copy of proof of USI Number) Education Agents Details If you were referred by an Education Agent, please provide details below Agent Name / Business Name: As an approved agent of Imperial, I am also certifying that I have verified all the original documents of the student. Signature: Student Declaration is collecting the information on this Application form for the purpose of assessing student s eligibility for the Higher Education Loan Program (HELP) under the Higher Education Support Act 2003. Students personal information will be collected by fair and lawful means which is necessary for the purpose of enrolment and function of Imperial and is committed to ensuring the confidentiality and security of the information provided. This policy is issued in accordance with the Higher Education Support Act 2003 (HESA) and the Privacy Act (2000). I understand that may refuse, vary, reverse or terminate my enrolment on the basis of untrue, misleading or incomplete information. I declare that all information provided in this application is complete and correct. I understand that failure to provide correct information or documentation in relation to this application may result in cancellation of my enrolment. Signature of applicant Signature of Parent or Legal Guardian (if applicant is under 18 years of age) Date Application Submission Submit completed Application to: Admissions Officer 212 Hoddle St, Abbotsford, Victoria 3067, Australia Postal Address: PO Box 375, Abbotsford, Victoria 3067, Australia Telephone: 03 9417 4777 Fax: 03 9417 4787 Email: domestic@imperial.edu.au Attach following documents: Evidence of date of birth Evidence of Australian Citizenship/Permanent Humanitarian Visa Evidence of USI Number Tax File Number Page 4 of 5
Office Use Only Date Application Received: Received by: Decision on Application: Accepted / Rejected Staff Signature: Date: Page 5 of 5