Hearing/deaf Physical Intellectual

Learning Mental illness

Acquired brain impairment Vision
Application Form 2018 Medical condition Other
(International Students)
(If yes, please contact Operations Manager)
Select the AQF Level qualification
22251VIC Certificate II in EAL (Access) SCHOOLING
22255VIC Certificate III in EAL (Futher Study) 12. What is your highest COMPLETED school level? (Tick ONE
22258VIC Certificate IV in EAL (Futher Study)
box only)
BSB51915 Diploma of Leadership and Management
BSB61015 Advanced Diploma of Leadership and Management Year 12
FNS50215 Diploma of Accounting Year 11
FNS60215 Advanced Diploma of Accounting
Year 10
Intake Month: Year 9 or below
Never attended school– Go to question 15
PERSONAL DETAILS
13. Are you still attending secondary school?
1. Family Name (Surname):
Yes No
Given Names:
14. In which YEAR did you complete that school level?
2. Date Of Birth (Day/Month/Year):
3. Gender (Tick ONE box only) Male Female
PREVIOUS QUALIFICATIONS ACHIEVED
4. What is the address of your usual residence?
15. Have you SUCCESSFULLY completed any of the following
Line 1:
qualifications?
Line 2: Yes No – Go to question 18
Suburb, Locality Or Town:
16. If YES, then tick ALL applicable boxes
State/Territory: Postcode:
Bachelor degree or higher degree
5. Email Address:
Mobile Number: Advanced diploma or associate degree
Diploma (or associate diploma)
LANGUAGE AND CULTURAL DIVERSITY Certificate IV (or advanced certificate/technician)
6. In which country were you born? Certificate III (or trade certificate)
Australia Other – please specify Certificate II Certificate I
7. Do you speak a language other than English at home? (If more Certificates other than the above
than one language, indicate the one that is spoken most often) 17. Please indicate in which COUNTRY did you complete
No, English only – Go to question 9 the qualifications:
Yes, other – please specify
8. How well do you speak English? EMPLOYMENT
Very well Well Not well Not at all 18. Of the following categories, which BEST describes your
9. Are you of Aboriginal or Torres Strait Islander origin? (For current employment status? (Tick ONE box only)
persons of both Aboriginal and Torres Strait Islander origin, mark Full-time employee Part-time employee
both ‘Yes’ boxes) Self employed – not employing others
No Yes, Aboriginal Yes, Torres Strait Islander Employer Employed – unpaid worker in a family business
Unemployed – seeking full-time work
DISABILITY Unemployed – seeking part-time work
10. Do you consider yourself to have a disability, impairment or Not employed – not seeking employment
long-term condition?
Yes No – Go to question 12. STUDY REASON
19. Of the following categories, which BEST describes your main
11. If you indicated the presence of a disability, impairment or
reason for undertaking this course/traineeship/apprenticeship?
long-term condition, please select the area(s) in the following list: (Tick ONE box only)
(You may indicate more than one area) To get a job To develop my existing business

© Mercury Institute of Victoria Pty Ltd (Ver 2.0) CRICOS Code: 03439M RTO: 41264 PAGE: 1
 To start my own business To try for a different career Do you require airport pick up? Yes No
To get a better job or promotion
It was a requirement of my job 27. How did you hear about this course?
Website Newspaper Google Ad Friend
I wanted extra skills for my job
Agent: Other:
To get into another course of study
For personal interest or self-development PRIVACY STATEMENT
Personal information may be collected and disclosed to relevant VET Regulatory
Other reasons bodies which may include verification of a student’s previous qualifications, NCVER,
Commonwealth and State Agencies, and Department of Immigration and Boarder
Protection (DIBP).
STUDENT IDENTIFICATION NUMBERS For any other third party the Institute will only release student information with the written
consent of the student. MIV will endeavour to take all reasonable steps to protect personal
20. Enter your Victorian Student Number (VSN) to be completed information from misuse, loss or unauthorized access, modification or disclosure.
by all students aged under 25: Privacy provisions set out how MIV will collect, use, keep, secure and disclose personal
information that it has obtained. This also gives the individual or student the right to
21. (USI) Enter your Unique Student identifier: know what information MIV holds about them and establishes a right to correct that
information if it is incorrect.
22. Have you attended any Victoria School since 2009 or had any MI will endeavour to take all reasonable steps to ensure that the information is accurate,
training with a Vocational Education and training (VET) registered complete and up to date.

training organisation provider or an Adult and community TERMS AND CONDITIONS

The date you agree to these terms & conditions is considered the Agreement Date.
education provider in Victoria since 2011? By accepting this Agreement you:
Yes – I have attended a Victoria School since 2009 1. Agree to comply with the Mercury Institute of Victoria (MIV) student Policies & procedures
as indicated in the MIV Student Handbook.
Yes – I have attended TAFE or Private provider for Vocational 2. Confirm that you fulfil all entry requirements in which you are enrolling;
a. Agree to pay all requisite fees associated and
Education and Training b. Upon receipt of the Course Fee if applicable, MIV agrees to:
No – I have not attended a Victoria School since 2009 or a c. supply you with initial course materials for your course;
d. provide you with access to the online student portal if applicable;
TAFE or VET training provider since the beginning of 2011 e. provide you with access to learning and administrative support;
If YES – Please list most recent Victorian School Attended: f. grade your assessments; and
3. The Course Fee does not include:
a. postage of any assessments or other materials by you to MIV or
b. any materials that are listed as “Computer Requirements” or “Additional
If YES – Please list most recent Vocational Education and Training Requirements” for your course on the MIV website. Please note that, depending on your
particular course, you may need to provide your own equipment in addition to the course
Provider Name: materials at your own expense.
4. On successful completion of all assessments and the full payment of the Course Fee if
applicable, MIV will issue you appropriate certification for your course.
NATIONALITY 5. MIV may make changes to your course, course materials and the MIV Student Policies
23. Country of citizenship: and Procedures as reasonably required.
6. $50 for a re-issue of a Certificate, Qualification or Statement of Attainment. For more
Passport No.: detail of your miscellaneous fee. See your MIV Student Handbook.
7. The course material that MIV provides to you shall become your property. However, the
Current VISA Type: Working Holiday content of the course materials, including copyright and all other such intellectual property
Student Tourist Permanent Resident rights contained therein, remain the property of MIV or a nominated third party. You may
not reproduce any part of the course materials without the prior written consent of MIV.
Post-Study Work Other: 8. The maximum duration of your course is specified on the MIV website In the event that
you do not complete the course within the maximum duration; your enrolment expires
EMERGENCY DETAIL OF NEXT OF KIN without refund. If you wish to extend your Course beyond the course expiry date, you must
apply before your visa duration finished for extension of your study.
24. Contact Person Name: 9. MIV reserves the right to cancel a course prior to course commencement date. In this
rare circumstance you are entitled to a full refund (or pro-rata adjusted refund) or transfer
Relation: Phone No: of funds to another future course. In this event, you will be given your preferred option. If a
refund is requested MIV will refund the fees within four weeks of the course cancellation.

RPL/CREDIT TRANSFER
Enrolment Declaration
25. Are you seeking recognition of prior learning (Please tick) I, __________________________________________, agree
Yes No that by signing this declaration:
(if you ticked “yes” you will need to contact MIV RPL assessor / training support manager
• I have read and understood and consent to the privacy notice and
have completed all questions and details on the enrolment form
for RPL application and other details) • The information herein provided is to the best of my knowledge
Are you seeking Credit transfer? true, correct and complete at the time of my enrolment
Yes No Student Singature:
(If you ticked “yes” you will need to provide certified copies of transcripts, course outlines

and subject descriptions for each unit of competency.)

ACCOMMODATION AND AIRPORT PICK UP Date:

26. Do you require accommodation? Yes No

© Mercury Institute of Victoria Pty Ltd (Ver 2.0) CRICOS Code: 03439M RTO: 41264 PAGE: 2