MITEnrolmentForm2014_V4 12
MIT COURSE ENROLMENT FORM COURSE DETAILS COURSE DATE COURSE FEE HOW DID YOU HEAR ABOUT US? STUDENT DETAILS FEMALE MALE TITLE FIRST NAME DATE OF BIRTH SURNAME POSTAL ADDRESS SUBURB STATE HOME PHONE MOBILE WORK PHONE FAX POSTCODE Please select... USI NUMBER (if(required) applicable): If you do not already have a USI number, please go to www.usi.gov.au to apply MSAC Member Full-time MSAC members are eligible for discount, Please contact MSAC institute of Training Part-time Work Area _____________________________________________ Casual LANGUAGE & CULTURAL DIVERSITY EDUCATION Do you speak a language other than English at home? Are you still attending secondary school? Yes No Please specify your highest COMPLETED school level? Yes No English only If yes, please specify: How well do you speak English? Very well Well Not well Completed Year 12 Completed Year 8 or lower Completed Year 9 or equivalent Not at all ARE YOU OF ABORIGINAL OR TORRES STRAIT ISLANDER ORIGIN? No Yes, Aboriginal Yes, Torres Strait Islander DISABILITY (We promote access to people of all abilities. Please let us know if you have any special requirements to undertake our course) Do you consider yourself to have a disability, impairment or long-term medical condition? Yes Have you SUCCESSFULLY COMPLETED any of the following qualifications (please tick relevant boxes): Diploma, Advanced Diploma or Associate Diploma If YES, please indicate the areas of disability, impairment or long-term condition by ticking the relevant boxes: (you may indicate more than one). Learning Mental Illness Vision Medical Condition Intellectual Acquired Brain Impairment Certificate IV or Advanced Certificate/Technician Certificate III or Trade Certificate Certificate II Certificate other than above Name of Qualification or Certificate: Do you require special assistance because of the disability?’ Yes In which YEAR did you complete that school level? Bachelor or Higher Degree No Hearing / Deaf Physical Other Completed Year 10 Completed Year 11 Never attended school STUDY REASON No EMPLOYMENT STATUS Please indicate which of the following categories BEST describes your current employment status? Full time employee Not employed – not seeking employment Unemployed – seeking part time work Self-employed (not employing others) Part time employee Unemployed – seeking full time work Employed – unpaid worker in a family business Please indicate which of the following categories BEST describes your main reason for undertaking this course/traineeship? (please tick one box ONLY) To get a job To get a better job or promotion To start my own business To develop my existing business I wanted extra skills for my job To get into another course of study For personal interest or self-development Other reasons PAYMENT DETAILS EFT DETAILS: ANZ Account Name: MSAC Institute of Training Online Store : Order Number CREDIT CARD: Please debit my credit card - VISA AMOUNT CARD TYPE CARD NUMBER Visa Account Number: 83 547 8854 MasterCard NAME CARDREQUEST DIRECTON DEBIT Mastercard BSB: 013 435 EXPIRY CCV AMEX I have read and understood Policies and Procedures in Student Guide, by visiting www.msacinstitue.com.au/studentresourcecentre DATE SIGNATURE SEND ENROLMENT FORM In Person Bring enrolment form and payment to: MSAC Institute of Training, Sports House, 375 Albert Road, Albert Park Mon-Fri 8.30am – 5.00pm By E-mail E-mail enrolment form to: MSAC Institute of Training, [email protected] (authorisation letter or purchase order required for invoice) By Fax Fax enrolment form to: MSAC Institute of Training, Fax: 03 9926 1333 (authorisation letter or purchase order required for invoice) STAFF TRAINING BUDGET FYTD: $ MIT APPROVAL AREA MANAGER APPROVAL DATE DATE GL CODE
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