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APPLICATION AND ENROLMENT FORM FOR CERTIFICATE III IN COMMUNITY PHARMACY SIR30116 1. Delivery Mode Online or Print Correspondence * Online Print Correspondence 2. Course Fee Arrangement Please Select one of the following arrangements.* Please Select Pay for first Module then pay by Payment Plan Payment In Full 3. Personal Details Please Select Title Ms Mrs Mr Dr Gender * Male Female Please tick if your postal address is the same as your residential address. Where you born in Australia? * Yes No If no, what Country were you born in? Are you of Aboriginal origin? * Yes No Are you of Torres Strait Islander origin? * Yes No USI Number (click here if you do NOT have one) What is your residency status? * Please Select Australian Citizen Australian Permanent Citizen Humanitarian Visa New Zealand Citizen None of the above Please enter your residential status 4. Emergency Contact 5. Education History What is your highest completed school level: Please Select Completed Year 12 Completed Year 10 Completed Year8 & below What year did you complete your highest level? * Please Select Year 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Are you currently employed? * Yes No If yes, what is your employment status? Please Select Full Time Part Time Casual Self Employed unemployed Have you completed any of the following in Australia? * Please Select Bachelor Degree or Higher Certificate IV (or Advanced Certificate/Technician) Certificate I Advanced Diploma or Associated Degree Certificate III (or Trade Certificate) Other Diploma or Advanced Diploma Certificate II Not applicable What is the MAIN reason you are enrolling into this course? * Please Select To get a job To develop my existing business To start my own business To try for a different Career To get a better job or a promotion It was a requirement of my job I wanted extra skills for my job To get into another course of study For personal interest and development (WA only) Other 6 .Language, Literacy, Numeracy (LLN) and Support Requirements This course requires an intermediate level of English skills. Please complete the following LLN assessment. This will allow us to provide you with any support you may need to complete the course. Do you speak a language other than English at home? * Yes No If yes, what language? Please Select English Mandarin Italian Arabic Greek Cantonese Vietnamese How well do you speak English? Please Select Very Well Well Not Well Not at all Do you feel that you may require assistance with Language, Literacy and/or Numeracy? Please Select No, Not at all Some assistance Lots of assistance Do you consider yourself to have a permanent disability, impairment or long term condition? * Please Select Yes No If YES, then please indicate the areas.(You may indicate more than one area) Please Select Acquired Brain Injury Hearing/Deaf Intellectual Learning Mental Illness Physical Vision Medical Condition Other Do you have any other support needs that may assist you in completing this course Yes No Please detail your support needs here Participant Declaration & Privacy Statement I have read and understood my Student Handbook and or Course Brochure made available to me. I understand the roles and responsibilities as the participant and that of the trainer / assessor. I understand the pathways and options available to me for training and assessment. I hereby agree to abide by the RTO policies and procedures relating to fees, charges and regulations of the organisation. I declare that the information supplied on this form is correct and complete. I agree that personal information and records (this may include written, verbal, photographic and other formats) collected by the Registered Training Organisation (RTO) may be used by the RTO for research, statistical analysis, program evaluation and internal management purposes, used by government departments for audit, research, statistical analysis, program evaluation and used for promotional and commercial purposes I understand that my personal information will only be disclosed to other third parties in accordance with the law and with the appropriate legal documents or agreement/ permission in writing by myself I am over 18 years old I also accept the above mentioned Terms and Conditions.* Just to further protect your information by making sure you are not a robot, please complete the following before sending. Security Code: *
This course requires an intermediate level of English skills. Please complete the following LLN assessment. This will allow us to provide you with any support you may need to complete the course.
Just to further protect your information by making sure you are not a robot, please complete the following before sending.
