Student Card Application for Distance Students PLEASE REFER TO THE BACK OF THIS FORM FOR INSTRUCTIONS AND INFORMATION ONLY STUDENTS WHO LIVE OUTSIDE MELBOURNE AND DO NOT ATTEND CAMPUS DURING SEMESTER SHOULD COMPLETE THIS FORM ALL APPLICANTS MUST: • Have completed all steps of their online enrolment • Include a certified copy of photographic identification • Upload your photograph via the CaptureME portal. IT IS IMPORTANT YOU READ PAGE 2 PRIOR TO COMPLETING THIS FORM Student ID Number Date of Birth Title (please circle) Mr Ms Miss Mrs Surname/Family Name _______________________________ Given/Other Names _________________________ Dr dd/mm/yy Other (specify) ___________ _ __________ _____ ________ ________________________________________ _ __________ Address Contact Phone No. _______________________________________________________________________ Course Name Course Code _________ _____________ __ _____________ The University of Melbourne collects personal information in accordance with the University Privacy Policy which can be viewed in full at http://www.unimelb.edu.au/unisec/privacypolicy.htm Information is collected, used and stored for the purpose of administering enrolment and related activities. Commonwealth and State agencies require certain information to be reported or disclosed by the University. You may request access to your information at any time by contacting the privacy officer at [email protected]. Student Signature Date Student Centre Use Only Date Received: ___/___/___ Processed By: Card Posted: __/___/____ Date Enrolment Confirmed: ___/___/____ X:\EMS\Forms\FRM Student Card Application for Distance Students.doc Version 1 091210 Student Card Application for Distance Students INSTRUCTIONS FOR STUDENT Your Student Card will be mailed to the address you indicate on this form. CHECK LIST Ensure you have completed all steps of your online enrolment. ALL applicants must include a certified copy of photographic identification, such as a drivers licence or passport. A certified copy is a photocopy of an original document that has been sighted (along with the original) by any of the following Professionals: • Doctor • Notary • Veterinary Surgeon • Police Officer • Dentist • Bank Manager • Justice of the Peace • Barrister • Pharmacist • Clerk of the Courts • Municipal Council Member • Solicitor Member of State or Federal Parliament • School Principal • Solicitor Please ensure that you have uploaded your photo to CaptureME portal EMAILING YOUR APPLICATION Please email your completed application form along with your proof of identification document to [email protected] from your University of Melbourne email account: X:\EMS\Forms\FRM Student Card Application for Distance Students.doc Version 1 091210