Application Form The information you provide in this form will be used only for purposes of admission to Intercultural Theatre Institute (ITI) and will be treated confidentially. Application for 2016 / 2017 / 2018 intake (circle appropriate). 1. Particulars of Applicant Name (underline surname): Photo Name in native script (where applicable): Address where you can be easily reached: Contact number (include country code): ( ) (mobile) ( ) (home) Email: Local Identity number / Passport number: (cicle where applicable) Date of Birth: Gender: F / M Place of Birth: Nationality (please tick): ⃝ Singapore Citizen ⃝ Permanent Resident ⃝ Others (please specify): Ethnicity: Religion: Marital Status: 2. Education a. Highest formal educational qualification: Intercultural Theatre Institure Ltd, Emily Hill, 11 Upper Wilkie Road, Singapore 228120, Republic of Singapore www.iti.edu.sg T +65 6338 5133 E [email protected] 1 b. English Language proficiency Academic or or other formal qualification e.g. GCE 'O levels or high school equivalent, IELTS, etc. (please indicate grade and/or Pass / Fail) * include a copy of the corresponding certificate or result transcript in Appendix C Written English: Spoken English: Fluent / Adequate / Need help Fluent / Adequate / Need help c. Other language proficiencies (circle appropriate level): Written: Fluent / Adequate / Need help Spoken: Fluent / Adequate / Need help Written: Fluent / Adequate / Need help Spoken: Fluent / Adequate / Need help Written: Fluent / Adequate / Need help Spoken: Fluent / Adequate / Need help Written: Fluent / Adequate / Need help Spoken: Fluent / Adequate / Need help Written: Fluent / Adequate / Need help Spoken: Fluent / Adequate / Need help d. Previous theatre training (if you need more space please attach a separate document) Nature of training/qualification Technical Theatre experience Stage Management ⃝ No experience ⃝ Beginner ⃝ Advanced ⃝ Very experienced Year/Duration Name of teacher/school Stage Lighting Stage Sound ⃝ No experience ⃝ Beginner ⃝ Advanced ⃝ Very experienced ⃝ No experience ⃝ Beginner ⃝ Advanced ⃝ Very experienced 3. Financial Support If you are offered a place, please indicate how you intend to support yourself: 1. Fee (Bursary/Scholarship, private funding, others - please state) 2. Maintenance (Bursary/Scholarship, private funding, others - please state) Intercultural Theatre Institure Ltd, Emily Hill, 11 Upper Wilkie Road, Singapore 228120, Republic of Singapore www.iti.edu.sg T +65 6338 5133 E [email protected] 2 4. Health History YES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 If yes, please explain: Difficulty with physical exercise Advice from a physician not to exercise Muscle, joint or spinal disorder that could be aggravated by exercise History of heart problems History of lung problems High or low blood pressure Chronic illness Recent surgery (within the past 6 months) Diabetes Glaucoma Are you pregnant Presently taking any medication, which may affect, or be affected by physical activity Gout Epilepsy Breathing difficulties or asthma Hernia Have you been hospitalised recently Present / recent infections or infectious diseases (describe) Please give a brief description of any past or current injuries, structural alignment problems or medical conditions not specified above. Are you currently receiving care through any of the following? YES 1 2 3 4 If yes, please explain: Physical Therapy Psychotherapy Chiropractor Others (please state) 5. Personal History YES Have you ever been convicted in a court of law in any country? Have you ever been prohibited from entering Singapore? Have you ever been refused entry into or deported from any country? Have you ever entered Singapore using a different passport or name? If any the answer is "YES", please furnish details on a separate sheet of paper. 6. Appendixes Please tick if submitted Appendix A Two letters of reference (preferably from arts practitioners/companies) Appendix B Experience in the arts Appendix C Previous learning experiences (Academic and others) (Please include all corresponding certificates/result transcripts.) Appendix D Employment experience Appendix E Statement of aspiration (tell us why you are interested in joining the programme) Appendix F Other things you wish to tell us (Optional) Intercultural Theatre Institure Ltd, Emily Hill, 11 Upper Wilkie Road, Singapore 228120, Republic of Singapore www.iti.edu.sg T +65 6338 5133 E [email protected] 3 7. Declaration by Applicant I declare that all the particulars furnished by me in this application are true. Signature of applicant Date Please send the form, along with 2 recent passport size photographs and all appendixes via: 1. Mail: Attn: Curriculum Coordinator Intercultural Theatre Institute 11 Upper Wilkie Road Singapore 228120 OR 2. Email: Scan and send the completed application form to [email protected]. Please retain the original for future submission. Application will be processed upon receipt of the application fee (non-refundable): $32.10 (Singapore dollars). Fee payable by any of the following methods: Local Payment 1. Cheque in SGD Cheques should be made payable to "Intercultural Theatre Institute Ltd". 2. Cash Payment may be made at the ITI Administration Office Overseas Payment 1. Telegraphic Transfer (T/T) T/T should be made payable to "Intercultural Theatre Institute Ltd". All bank charges are to be borne by the applicant. 3. Bank Transfer ITI’s bank account payment information is: Bank: United Overseas Bank Bank No: 7375 Branch: Rochor Branch No: 047 Branch Address: 149 Rochor Road #01-26, Fu Lu Shou Complex, Singapore 188425 Bank Account Name: Intercultural Theatre Institute Ltd Bank Account No: 354-302-123-5 SWIFT Code: UOVBSGSG How did you hear about ITI? ¡ Collaterals (brochures, flyers, posters, etc.) ¡ Social Media ¡ Newspaper / magazine (Which? ________________) ¡ Word-of-mouth (Who? ___________________) ¡ Online features / listings ¡ Other: ___________________ For official use only Reference No: Date Received: Receipt No: Received by: Requires English Proficiency Test: Yes / No Director's Signature: Intercultural Theatre Institure Ltd, Emily Hill, 11 Upper Wilkie Road, Singapore 228120, Republic of Singapore www.iti.edu.sg T +65 6338 5133 E [email protected] 4
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