* Title: Please Select Mr Mrs Miss Ms Dr Other
* Family Name:

* Given Name(s):

Please print your name as you would like it to appear on your Certificate or Statement of Attainment:

* Residential Address:
* Postcode:
Postal Address:
    Postcode:
* Home Phone Number:

* Work Phone Number:

Mobile Phone Number:

* E-mail Address:

* Date of Birth: (DD/MM/YYYY)

*Country of Birth:

Emergency/Next of Kin Contact Details:
Name:

Home Phone Number:

Work Phone Number:

Mobile Phone Number:

* Are you of Aboriginal or Torres Strait Islander origin?: Please Select No Yes, Aboriginal Yes, Torres Strait Islander Yes, Aboriginal and Torres Strait Islander

* Where you born in Australia?:
Please Select Yes No If not, please specify:

* Do you speak a language other than English?:
Please Select No, English only Yes, other - please specify If yes, please specify:
If you speak a language other than English, how well do you speak English?: Please Select Very Well Well Not Well Not at all

* Do you consider that you have a disability, impairment or long-term condition?:
No     Yes    
If yes(*) please tick.
Vision    Hearing/Deaf     Physical    Intellectual     Learning
Medical Condition    Medical Illness    Acquired Brain Impairment     Other

* Your Employment Status
Please Select Full-time employment
Part-time employment
Casual employment
Self employed - not employing others
Employer
Employer - unpaid worker in a family business
Unemployed - seeking full time work
Unemployed - seeking part-time work
Not employed - not seeking employment

If employed(*), please specify:

* What is your highest completed school level?: Please Select Completed year 12 Completed year 11 Completed year 10 Completed year 9 Completed year 8 or lower Did not go to school

In which year did you complete that school level?: Please Select 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1993 1992 1990 1989 1988 1987 1986 1985 1984 1983 1983 1982 1980 1979 1978 1977 1976 1975 1974 1973 1973 1972 1970 Before 1970

Name of institution completed at:

Are you still attending secondary school?: Please Select No Yes

* Have you completed any of the following qualifications?: Please Select No Yes
If Yes please tick:

* National Code of Qualification enrolling for:

* Title of Qualification enrolling for:

* Reason for study: Please Select To Get a Job To start my own business To get a better job or promotion I wanted extra skills for my job For personal interest To develop my existing business To try for a different career It was a requirement for my job To get into another course of study For self-development Other reasons

Further, I authorise Work Plus to seek information about any aspect of the course/qualification, we are undertaking for the purpose of properly managing the qualification processes. This may include obtaining copies of relevant forms and documents, progress reports and quality checks. Such information may be gathered from the relevant State Training Authority, other Registered Training Organisations, the Commonwealth Department of Education Science & Technology, and the New Apprenticeship Centre. Personal information will be managed in accordance with the Personal Information Protection Act 2004 and may be accessed by the individual to whom it relates on request to Principal. I understand that Work Plus will not pass this information to any other party without my written permission.

* By checking this box, I certify that all details provided on these forms are correct, and I understand that information contained in these forms may be provided to State and Commonwealth education and research agencies and I consent to that occurring. For fee paying courses, I understand that no certificate will be issued until all fees are paid in full. I declare that all details provided in this form are correct.