2013 UQ Q Enhancced Stud dies Proggram (ESP P) Sample Applicattion Guid de Please use tthis examplee to view the questions aand prepare tthe informattion requiredd to complette your ESP application online. You must answer ALL questioons IMPORT TANT – Pleasse read this before proceeding n official UQ Enhanced S tudies Progrram Application Form. Suubmitted cop pies of this This document is not an b accepted d as an a pplication. Please submit your aapplication online at document will not be du.au/esp/ho ow‐to‐apply www.uq.ed Before subm mitting your application please ensu re you have read the ESP Rules and Guidelines a available at www.uq.ed du.au/esp/do ocs/2013‐ESP P‐Rules‐and‐‐Guidelines.p pdf Online Appllication Form ms and all supporting doccumentation n for the 201 13 Enhanced Studies Program must be received d by 5pm We ednesday 31st October 22012. Late ap pplications w will NOT be coonsidered. Section 1 Name Full Given N Name * Last Name * (ie. first and d middle) Thiis must be yo ou legal nam me that appears on your b birth certificaate/passportt Preferred N Name * Gender * Date of Birtth * Do you iden ntify as being of Aborigin nal or Torress Strait Islan nder descent? * Yes No o Address Postal Addrress : Street / PO Box * State * * Postcode * Suburb/Tow wn * School Do you atteend a Queen nsland schoo ol? * Yes Noo School Nam me* What is you ur Learner Unique Identiifier Numbe r (LUI)? * Your LUI is a a 10‐digit nu umber that the QSA usess to identify yyou – please check with yyour school or the QSA to find yourr LUI Contact ne * Home Phon Mobile Pho one * Email * u use as parrt of your ap pplication must be uniquue to you. iee. an email Please notee: The email address you address tha at is NOT sh hared by fam mily memberrs or others, please also o ensure thaat your spam m filter will accept ema ails from addresses ending in @uq.eddu.au 2013 UQ En nhanced Stud dies Program m ‐ Sample A Application G Guide Page 1 of 3 Section 2 Citizenship Are you an International Student? * Yes No What is your Citizenship Status? *(Choose one ‐ If you were born in Australia and permanently live in Australia you will most likely be an Australian Citizen) Australian Citizen Australian Permanent Resident New Zealand Citizen Permanent Humanitarian Visa Holder Other Temporary Resident Holder of a Student Visa Country of Permanent Residence * Postcode for Permanent Residence. * Country of Birth * Year of Arrival in Australia* International Student Information Do you speak a language other than English at home? * Yes No If yes, what other language do you speak at home? * Parent/Guardian details Title * First Name * Last Name * Home Phone * Work Phone * Mobile Phone * Email Address * Relationship to Applicant * School Contact Information Please enter the contact details of your ESP School Contact. Your school contact may be a Guidance Officer, Year 12 Coordinator, Head of Department or Principal and will be responsible for monitoring your ESP progress. Title * First Name * Last Name * Position at school* Phone Number * Email Address * Medical Information This information is used only to provide advice and support services to students and will not affect your application Do you have a disability, impairment, or long term medical condition that may affect your studies? * Yes No Please supply details of above medical condition or impairment. * Would you like to receive advice on support services, equipment and facilities which may assist you? * Yes No 2013 UQ Enhanced Studies Program ‐ Sample Application Guide Page 2 of 3 Section 3 ESP Course Please nominate a first and second ESP course preference; you will most likely be given your first preference ESP Course ‐ 1st Preference Course * Location (Campus) * Mode * Mode * ESP Course ‐ 2nd Preference Course * Location (Campus) * Language Information If you have selected a language course, how many years have you been studying/speaking this language? * Please indicate your level of competency in this language: * Never previously studied Beginner Basic Intermediate Advanced/Fluent Native Speaker Privacy statement: The information on this form is collected for the primary purpose of assessing your application for the 2013 Enhanced Studies Program. Personal information may be disclosed to your school for verification of your studies to make an informed decision about the application. Otherwise your information will remain confidential and will not be disclosed to a third party without your consent unless disclosure is authorised or required by law. For further information please consult the UQ Privacy Management Policy at: https://ppl.app.uq.edu.au/content/1.60.02‐privacy‐management I accept: * Yes No To be considered for the Program, your Online Application Form and all supporting documentation must be received by UQ by no later than 5pm, Wednesday 31 October 2012. You will receive an email to confirm that your application has been received. It is your responsibility to contact the UQ ESP Coordinator by emailing [email protected] or by phone on (07) 3346 7762 if you have not received this confirmation email within two working days of submitting your application. 2013 UQ Enhanced Studies Program ‐ Sample Application Guide Page 3 of 3