Anda di halaman 1dari 4

Deakin University CRICOS Provider Code: 00113B

NO. & STREET


SUBURB
EMAIL
APPLICATION AND ENROLMENT
RETURN TO PRACTICE AND INITIAL REGISTRATION
(OVERSEAS NURSES)
PREVIOUS NAME
(if applicable)
TITLE SURNAME
gender (M or f) daTe of birTH
TEL (Home) TEL (business)
TEL (Mobile) fax
STATE
counTry
posTcode
GIVEN NAMES
fee caTegory
basis for
ADMISSION
gender (M& f)
course code
H011
locaTion
B
MODE Type
correspondence caT.
applicaTion
Keyed by
SECTION 2: POSTAL ADDRESS
STUDENT ID NUMBER
please complete if you are a former deakin student
SECTION 4: AHPRA LETTER
please atach a certfed copy of leter from aHpra dated within 1 year.
SECTION 6: RECORD OF RESULTS AND PROOF OF COURSE COMPLETION
please atach a certfed english translaton of your record of results and proof of course completon.
SECTION 7: NURSING REGISTRATION/LICENCE
please atach a certfed copy of your nursing registraton.
SECTION 3: AUSTRALIAN PERMANENT RESIDENCY
please atach a certfed copy of australian residency status (not applicable to citzens of australia).
SECTION 1: PERSONAL DETAILS OFFICE USE ONLY SECTION 1: PERSONAL DETAILS OFFICE USE ONLY - DSA AND FACULTY
SECTION 5: ENGLISH LANGUAGE PROFICIENCY (not applicable to return to practice students)
applicants must provide certfed documentary evidence of english profciency.
Which of the following have you atained:
an overall b pass in occupaTional englisH TesT (oeT).
inTernaTional englisH language TesTing sysTeM (ielTs) acadeMic Module:
a score of aT leasT 7 in all four coMponenTs of ielTs (reading; lisTening;
WriTing and speaKing) WiTH an overall band score of aT leasT 7.
please indicaTe
TEST DATE
please indicaTe
TEST DATE
PROF QUAL
N U
offered noT offered
selecTion officer
NAME
SIGNATURE
TelepHone
exTension
DATE
/ /
DATE
/ /
Deakin University CRICOS Provider Code: 00113B
SECTION 11: FINAL CHECKLIST
use this checklist to ensure that you have completed all the steps necessary for your applicaton. you may miss out if your applicaton is incomplete.
Tick if you have completed all relevant sectons of this applicaton form
Tick if you have included certfed copies of original documents of all relevant documentaton
Tick if you have included all relevant supportng informaton
Tick if you have signed the declaraton
Tick if you have completed the diisrTe statstcs on the next page.
SECTION 8: TERTIARY EDUCATION
are you already enrolled in a deakin course?

yes no
Have you ever been excluded or expelled from a course at any insttuton?

yes no (if yes, please supply details)
if your previous studies were at deakin or one of its antecedent insttutons, your applicaton will be handled more expeditously if you supply a certfed copy of
your academic transcript. if this is not possible, please provide your student number and the last year of your enrolment.
deakin student id


last year of enrolment

Have you atempted a return to practce/inital registraton (overseas nurses) course previously?

yes no
if yes, please indicate the name of the insttuton.

date
SECTION 9: EDUCATIONAL HISTORY
QualificaTions year INSTITUTION counTry are docuMenTs
aTTacHed? (y/n)
SECTION 10: NURSING EXPERIENCE
in additon to completng this secton please atach a brief summary of your recent nursing responsibilites as evidence of practce.
eMployer year
finisHed
year
STARTED
POSITION counTry full-TiMe/
parT-TiMe
Deakin University CRICOS Provider Code: 00113B
SECTION 12: DECLARATION
i declare that to the best of my knowledge the informaton supplied in this applicaton and the documentaton supportng it are correct and complete.
Where records of prior study have been provided in support of my applicaton, i authorise deakin university to conduct a search and retrieval of my academic
record from my previous insttuton/s to verify the informaton contained in my applicaton.
i acknowledge that the provision of incorrect informaton or documentaton relatng to my applicaton may result in withdrawal of any ofer of a place and that
such withdrawal may take place at any stage of the course, at the discreton of deakin university.
i agree to abide by the statutes, rules and regulatons of the university.
i consent to such of my personal identfying data being provided to diiccsrTe (department of industry, innovaton, climate change, science, research and
Tertary educaton) as is necessary for allocaton of a cHessn (commonwealth Higher educaton student support number), and
my sle (student learning enttlement).
for internatonal students only i declare that i am in possession of the appropriate visa for my intended study program.
SECTION 13: UNIT DETAILS
doMesTic applicanTs please
direcT applicaTions To:
professional development unit
school of nursing and Midwifery
deakin university,
Melbourne burwood campus
221 burwood Highway
burwood vic 3125
phone: +61 3 92517776
fax: +61 2 92446159
deakin universitys privacy statement can be found at
www.deakin.edu.au/web-disclaimer
SIGNATURE
DATE
inTernaTional applicanTs
please direcT applicaTions To:
international admissions coordinator
deakin international
deakin university,
Melbourne burwood campus
221 burwood Highway,
burwood. victoria 3125
australia
Joseph dwyer on phone: +61 3 9627 4877
fax: + 61 3 9244 5094
http://www.deakin.edu.au/future-students/
international/apply-entry/index.php
unit code
Hnn021

unit name
nursing pracTice in ausTralia
period


cT2 (May)
campus geelong geelong

Melbourne

Warrnambool
Waterfront Waurn ponds burwood
class
x
d (day)

e (evening)

x (of-campus)
1

credit point value
x
unit code
Hnn026

unit name
legal, eTHical and conTeMporary issues in ausTralian
nursing pracTice
period


cT2 (May)
campus geelong geelong

Melbourne

Warrnambool
Waterfront Waurn ponds burwood
class
x
d (day)

e (evening)

x (of-campus)
1

credit point value
x
unit code
Hnn025

unit name
clinical pracTicuM
period


cT2 (May)
campus geelong geelong

Melbourne

Warrnambool
Waterfront Waurn ponds burwood
class
x
d (day)

e (evening)

x (of-campus)
2

credit point value
x
Deakin University CRICOS Provider Code: 00113B
STATISTICS
are you of aboriginal or Torres strait islander descent?
(select one only)
please indicate your parents/guardians gender and highest
level of educaton.
What is the highest atainment of educaton you completed prior to this
course? (select one only)
if you have undertaken prior undergraduate studies please provide the
name of the insttuton at which you studied?
parent 1 parent 2
01 09
10
11
no
Male Male yesaboriginal
female female
parent 1 parent 1
postgraduate qualifcaton
did not complete year 12 or equivalent
other post school qualifcaton
did not complete year 10 or equivalent
bachelor degree
completed year 10 or equivalent
completed year 12 or equivalent
a complete higher educaton postgraduate course
no prior educatonal atainment
a complete higher educaton sub-degree course
an incomplete Tafe (vTe) award course
last year of enrolment was
a complete higher educaton bachelors degree course
a complete Tafe (vTe) award course
an incomplete higher educaton course
not sure
yesTorres strait islander
yesaboriginal and Torres strait islander
What is your citzenship status during this year?
(select one only)
if you are a student who is a new Zealand citzen,has
permanent residence status, or is the holder of a permanent
Humanitarian visa, select a statement that best describes your
circumstance below.
02
03
you are residing inside australia for the Trimester or outside aus-
tralia as a requirement of the course.
a complete fnal year of secondary educaton course
(at school or Tafe)
you are residing outside australia for the Trimester but not
because of a requirement of the course.
a complete other qualifcaton or certfcate of atainment
or competence
australian citzen
other status
Temporary entry permit Holder
permanent Humanitarian visa Holder (proof requiredsee 03)
new Zealand citzen (see 03)
in what country is your permanent home address during the year? 04
if yes to 12, please indicate the area(s) of impairment. 13
australia postcode
other country name
australia postcode
other country name
in what country is your residence during the year? 05
in what country were you born? 06
if you are an australian school leaver, what was your home postcode in
your last year of secondary school?
08
australia
Hearing
vision
other country
year of arrival into australia
yes no
do you speak a language other than english at your permanent home
residence?
07
yes no
do you have a disability, impairment or long-term medical conditon
which may afect your studies?
12
yes no
if yes to 12, would you like to receive advice on support services,
equipment and facilites which may assist you?
14
language Mobility
other
learning
Medical
SIGNATURE DATE
i hereby declare that the informaton provided is correct and complete:
your enrolment cannot be completed if these statstcs are not provided.
These statstcs are required by the department of industry, innovaton, climate change, science, research and Tertary educaton (diiccsrTe) pursuant to subdivision 19-70(1) of the Higher
educaton support act 2003. The statstcs are collated and provided to diiccsrTe and do not identfy individual students.