Menzies OBA Preparation Program |
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1. PERSONAL DETAILS |
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Title |
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Family name (as in passport) |
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Given name(s) (as in passport) |
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Date of birth |
Gender ☐ Male ☐ Female ☐ Other or Non-disclosed |
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Nationality (as per your passport) |
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Phone/Mobile (with country code) |
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Email Address |
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Address in Home Country |
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Address |
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Suburb / Town |
Postcode: |
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Country |
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Address in Australia (if known) |
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Address |
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Suburb / Town |
Postcode: |
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Country |
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Emergency Contact Details |
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Contact Name |
Phone Number |
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Mobile Number |
Relationship |
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Medical Conditions |
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Do you have a known disability or medical conditions? (e.g. intellectual, hearing, vision, etc.) ☐ YES ☐ NO If YES (give details and contact our admin team) |
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2. PASSPORT AND VISA DETAILS |
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Country of Birth |
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Citizenship |
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Passport Number |
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3. ENGLISH PROFICIENCY |
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Please provide certified copies of meeting the English language skills requirement as outlined here: https://www.nursingmidwiferyboard.gov.au/Registration-Standards/English-language-skills.aspx |
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IELTS Score TOEFL Score PTE Score Other (please specify) (Overall) Test Date: __________ |
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e Specify) |
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4. INTAKE MONTH |
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Month _________________________ Year_________________________ |
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5. EDUCATION AGENT DETAILS (If applicable) |
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Who is your Education Agent? |
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Agent Name |
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Agency name |
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Address |
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I authorise the agent selected to act on my behalf: ☐ Authorise education agent |
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Agent declaration I am satisfied that the applicant is a genuine student and I recommend them for admission to MENZIES Institute of Technology. I am satisfied that the applicant has access to sufficient funds to cover tuition, travel, living costs for themselves and any dependants. I confirm that the supporting documentation provided with this application are the true copy of the originals which are/were sighted by me and can confirm their authenticity and genuineness. Agent Signature: ________________________ Date: _______________________ |
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8. STUDENT DECLARATION |
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________________________________ _______________________ Applicant Signature Date _______________________________ Applicant Name |