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