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IRMT Student Graduate Application Form 2015
APPLICATION for the status of STUDENT GRADUATE - from 2015
NB Please ensure that the form used has the year of application on it.
“Student Graduate” is a category of unregistered membership in the IRMT. The Registration Board of the
IRMT, on behalf of the Council may, upon application, grant the status of Student Graduate for a period not
exceeding five years to persons who have recently completed a university music degree or a qualification in
performance and/or teaching of music from an examination board recognised by the Institute. The purpose
of this category is to help provide new teachers with support and assistance to build the experience
required to become Registered Members of the Institute.
A
PERSONAL INFORMATION
1.
PLEASE PRINT ALL INFORMATION
Given Names (underline most commonly used name)
_____________________________________________
Family Name (if using a name other than your legal name, please add this in brackets)
_____________________________________________
(Please precede this with MR / MRS / MISS / MS / DR or other designation)
2.
State complete preferred name for Listing (one first name or initials)
______________________________________________
3.
Address (maximum of three lines)
(No. & Street/PO Box)
(District/Suburb)
________________________________________________
___________________________________________________
(City/Town) _____________________________ Post Code
4.
_________________
Name and Address of current teacher who can act as Referee
_______________________________________________________________
_______________________________________________________________
__________________________ Tel_________ Email_____________________
5.
To include in listing:
Tel (0
)_________________
Email_______________________________________________
Website_______________________________________________
Note – email address is mandatory. This is the main form of communication
with our members and MUST be supplied.
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6.
IRMT Student Graduate Application Form 2015
For IRMT use only:
Mobile (0
)________________________
Fax No (0___)__________________ Private Tel (0___)________________
B1
7.
Date of birth
_______________ [minimum age for Student Graduate status is 16]
8.
NZ/Australian Citizen
Residency Visa
 (tick one)
 
Length of residence in NZ ___ years
MUSIC QUALIFICATIONS and MUSICAL EXPERIENCE INCLUDING ANY TEACHING
Title of Certificate (& Abbreviation)
i
Year
Examining body
_____________________________________
____ ____________________
ii _____________________________________
____ ____________________
iii _____________________________________
____ ____________________
(Please use a separate sheet for other qualifications and musical/ teaching experience)
B2
CATEGORIES
List the category / categories of music tuition for which you are seeking Student Graduate
status (for example, Piano, Voice, Violin, Theory etc)
____________________________________________________________________
C
DECLARATIONS
Have you ever been convicted of an offence against the law?
Yes / No (circle one)
If the answer is ‘Yes’ you are asked to provide details in confidence.
I do solemnly and sincerely declare that to the best of my knowledge and belief, all the
information given above is entirely true and correct.
Upon being granted Student Graduate status I agree to be bound by the terms of the Music
Teachers’ Act 1981, by the Rules of the Institute, and by the Code of Ethics as prescribed
by the Council of the Institute.
Signed_____________________________ Date ______________________
Name (PLEASE PRINT)_____________________________________________
D
POLICE CHECK
In line with current practice in the teaching profession, IRMTNZ requires new applications
to agree to a search of Ministry of Justice records for any convictions. An applicant must
provide a copy of the form Ministry of Justice Request for Criminal Conviction History –
Third Party (available on the IRMTNZ website) giving authority for such information to be
provided to the IRMTNZ’s Registrar. You must complete Steps 2, 3, 4 and if appropriate
Step 5 of this form. Leave Step 1 blank for the Registrar to complete. These details will
remain strictly confidential.
Applicants are advised to keep a copy of their application
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IRMT Student Graduate Application Form 2015
Note: Your application will be considered by the Registration Board of the IRMT and the
Registrar will notify you of the outcome.
In the event of being granted Student Graduate status by the Registration Board, the
Student Graduate is able to designate themselves as per the following example:
Jillian Smith Student Graduate Member (IRMT)
On no account is the Student Graduate member able to use abbreviations to designate
their membership status.
APPLICATION FEE $47.83
GST
$ 7.17
TOTAL
$55.00
Paying electronically (preferred method):
Bank: ANZ
Account Name: IRMTNZ
Account No: 060501-0462799-00
Code: your name
Reference: “Student Grad”
Note: Please ensure you include your name
so that we know who has sent us the payment
IRMT GST No. 21 - 071 - 161
This application fee will remain at this rate
until 1 February 2016. This fee also covers
student graduate membership until 31 March
2016.
Paying by cheque: Please make cheques
payable to Institute of Registered Music
Teachers of NZ
Email Application Form and attachments to:
The Registrar at [email protected]
Alternatively post them to: IRMTNZ Registrar,
PO Box 4122, Christchurch 8140
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