APPLICATIONFORM

ADMISSIONSTOHONOURSCOURSE

Thisformistobeusedfor admissiontothe School of Medicinehonours course.

Fullinformation:

FlindersStudentID(if applicable): / Areyou aDomesticor InternationalStudent?(Pleasetick)
Familyname: / DomesticStudentInternational Student
Firstname: / Emailaddress:
Dateof birth: / Telephone:
PostalAddress:
Proposedfield ofstudyforhonoursthesis:
Iwish to undertakethiscoursein:Year201 Semester 1 / Semester2Full-time / Part-time
3.CITIZENSHIPSTATUS
Areyou anAustralianCitizen?Yes No
Areyou aNewZealandCitizen?Yes No
Haveyou been granted aPermanentHumanitarianVisainAustralia?Yes No
Haveyou been grantedPermanentResidency(otherthan apermanenthumanitarianvisa) in Australia? / Yes / No
Year of entrytoAustraliaDateresidencygranted (if applicable)
Countryof birth
4.OTHERINFORMATION
Areyou anAboriginal or TorresStraitIslander?Yes No
Areyoufromanon Englishspeakingbackground? Yes No
What isthemainlanguagespokeninyourplaceof residence?
5. Supervisor details
Name of principalsupervisor:
Name of associate supervisors (if any):
Certification by Primary Supervisor:
I agree to be the principalsupervisor of this applicant in the field of research indicated on this form. If the applicant has a GPA of less than 5.0(i) I confirm that I have discussed the applicant’s academic performance, (ii) I strongly support the application, (iii) I am prepared to justify the case for an exemption to the GPA entry criterion for the applicant, and (iv) I have considered any additional support the applicant may require and I am prepared to provide such support.
Signature: ______Date: ____/____/______
Signature: Date:// ______

CRICOSProviderNo.00114A

Originalorcertifiedcopiesofresultsfor thequalificationonwhichyouareusing asthebasisfor admission(showingallsubjectsattemptedandgradesreceived,except forstudiesundertakenat FlindersUniversity),MUSTbeattached forthisapplication tobeprocessed.

List, inchronologicalorder,SecondarySchool studies,TAFE/VETqualifications,UniversityDegreesand Awardsyouhaveundertaken
Nameofaward/degree / Institution / Major field ofstudy / Year completedorexpected tocomplete / If uncompleted,enteryear last enrolled
7.DETAILSOFRELEVANTEMPLOYMENTOROTHERACTIVITIES
Position / Organisation / Startdate / EndDate
9.APPLICATIONFORADMISSION
I certify thattothebestofmy knowledgealldocumentationandinformationsubmittedormadeavailablebymetotheUniversity,whetherinrelationtoany courseofstudy or otherwise, istrue,accurateandcomplete.
I acknowledgethat theprovisionofinaccurateor incompleteinformationbymyself, oracertifyingauthority,may resultinthewithdrawalof any offer ofenrolment,or thecancellationofany enrolmentallowedonthebasis of acceptanceof thatoffer.
I consent tothecollection,storageanddisclosureof informationrelatingtorecordfalsificationor otherirregularactsinaccordancewithUniversitiesAustraliaprocedures.I authoriseFlindersUniversity toobtainfromothereducationalinstitutionsdetails of my enrolmentandacademicrecordatthoseinstitutions.
I understandthatFlinders University may disclosethepersonalinformationIhavegiveninthis applicationtotheDepartment ofEducation(DE) andthatDEwillcollectandstoremy personalinformationintheHigherEducationInformationManagementSystem.
Signature:Date://
APPLICATIONRETURN FURTHERINFORMATION
Thisformmustbereturnedto:
Ms Ashleigh Merriel
Faculty of Medicine, Nursing and Health Sciences
Level 3, Health Sciences Building
Flinders University
GPO Box 2100
Adelaide SA 5001 / For furtherdetails pleasecontact:
Ms Ashleigh Merriel
OfficePhone:08 8201 5470
Email:
Web:

FlindersUniversitycollects,storesandusespersonalinformationonlyforthepurposesofadministeringstudentand prospective studentadmissions,enrolmentandeducation.Theinformationcollectedisconfidentialandwillnotbedisclosedtothirdpartieswithoutyourconsent,excepttomeetgovernment,legalorotherregulatoryauthorityrequirements.