Certtificate III Application Form

Office use only

Application Rec’d:

/ /

RPL fee Rec’d: $100

(if applicable)

Receipt No:

Deposit Rec’d: $

Receipt No:

Accepted on course: Yes 0 Wait List 0

Please complete the following details:

First name:		(Preferred Name)
Surname:

Date of Birth: / / Sex M F

Contact Details

Street address:
Suburb/Town:	P/Code:
Day time phone:	Mobile phone:
After hours phone:	Email:
*In case of emergency contact: Name*		Phone:

Please Note: Students are required to familiarize themselves with the Course prerequisites detailed in the student information pack:

I, the undersigned understand and meet the aforementioned prerequisites. Additionally, to my knowledge I do not have a physical or medical condition that would preclude risk or affect my participation in this course.

Applicants Signature:

Date:

Applications must be received approx one month prior to a course commencing.

Please check our web site www.dcehpp.com.au for course scheduling and
application closing dates

or please call (03) 99030101

1. Of the following categories, which best describes your current employment status? (tick one box only)

Full-time employee		Part-time employee

Self employed – not employing others		Employer

Employed – unpaid family worker		Unemployed – seeking full time work

Not employed – not seeking employment		Unemployed – seeking part time work

Have you successfully completed any of the following qualifications? Yes No (If yes, tick any applicable boxes)

Bachelor Degree or Higher Degree		Certificate III (or Trade Certificate)

Advanced Diploma or Associate Degree		Certificate II

Diploma (or Associate Diploma)		Certificate I

Certificate IV (or Advanced Certificate/Technician)		Certificates other than the above

What is your highest COMPLETED school level? (tick one box only)

Year 12	Year 11	Year 10

Year 9 or equivalent	Year 8 or lower	Did not go to school

In which year did you complete that school level?

Where you born in Australia? Yes No - Please specify ___________________________

Do you speak a language other than English at home?

No, English only Yes, other – please specify _________________________

How well do you speak English?

Very Well

Well

Not well

Not at all

Are you of Aboriginal or Torres Strait Islander origin?

Yes, Aboriginal

Yes, Torres Strait Islander

Do you consider yourself to have a disability? Yes No If YES, then please indicate the areas of disability, impairment or long-term condition?

(You may indicate more than one area)

Hearing/Deaf	Acquired Brain Impairment	Physical	Vision

Intellectual	Medical Condition	Mental Illness	Other

Of the following categories, which best describes your main reason for undertaking this course? (tick one box only)

To get a job		I wanted extra skills for my job

To develop my existing business		To get into another course of study

To start my own business		For personal interest

To try for a different career		For self development

To get a better job or promotion		To get a qualification

It was a requirement of my job		Other reasons

Course Prerequisites:- Police Check, certified copy of driving license, Level 2 first Aid Certificate and
Must be able to drive a manual vehicle

Have you applied for RPL in relation to this course? No0 Yes0

If yes, DO NOT complete this form, your RPL is your application. Our administrative staff will notify you what course requirements and costs will be.

Do you have any convictions, findings of guilt and/or pending charges against you?

No0 Yes0

Please list offences below:

Applicants Signature:		Date:

If yes, your application will be assessed prior to acceptance into the course.

Employment Agency sponsorship

Have you been sponsored by an Employment agency? No0 Yes0

If YES, Please provide a letter from the agency outlining the percentage of money to be paid by the agency and the applicant.

Please note your application will not be accepted with out confirmation from the agency.

Qualifications:

List in order, your vocational qualifications and work experiences (you may include any community/voluntary training and/or service that are relevant to patient care activities i.e. St John /S.E.S)

______________________________________________________________________________

Note: In regard to the Cert III driving component, it is essential that you understand the importance of being a competent driver. Therefore are you a road user and do in fact drive a vehicle regularly. Rationale – students are required to practice road craft techniques in their own time consistent with the theory and supervised practical components as learnt during module four of the Cert III course.

Do you have a current Victorian Drivers Licence? Yes0 No0

Applicants Licence Number: _________________________________ Expiry date: __________________

Applicants Licence witnessed by: __________________________________________________________

(Please print name)

Signature of witness: ___________________________________________________________________

Do you own / have access to a vehicle for driving purposes? Yes0 No0

Estimate the weekly hours that you would drive a vehicle in normal road use: ____________Hrs

Do you hold a Current Level Two First Aid Certificate? Yes0 No0

(Note: A Level Two First Aid Certificate is a mandatory course prerequisite)

IMPORTANT: Applicants MUST provide CERTIFIED COPIES of all Certificates and/or Academic accreditation statements/achievements. (Certified Copies = The original certificate and a copy were presented to a person who is authorised to verify that the copy was compared against the original i.e. Justice of the Peace /Police etc.)

NOTE: The NECT course has limited vacancies. Therefore, applications received complete with $800 deposit will be accepted in order of receipt. Other/Late applications will be placed on waiting list.

Rationale: This check list is intended to support the applicant in ensuring that all relevant and required documentation and copies are included with the completed application form in readiness to be submitted.

It is important to note that there are limited vacancies for the Certificate III course, therefore only applications that are fully completed and accompanied with the relevant documents and the required deposit of $800.00 will be accepted in order of receipt. Incomplete forms or incomplete supply of documentation means that your application will be returned to you. This may delay your application and potentially restrict your entry into the course.

DCEHPP reluctantly takes this approach, but it is necessary to ensure fairness and consistency to all valued applicants.

When the course reaches the required number of participants, the remaining applications will be notified and if agreed, placed on a waiting list and in the event of a withdrawal an offer may be made for inclusion into the course.

My list of requirements

Have I provided letter from employment agency? (If applicable)

I Have put the required details of my licence on the application form

*And* included a certified copy to be sent with the application?

I Have included a certified copy of my First Aid Certificate with my Application Form

I have NOT completed an RPL form in relation to this application (This form should not be used in conjunction with an RPL request)

I Have included my $800.00 deposit with the Application Form?(Attach Cheque/Money order or pay by Credit Card write details below)
Credit Card Number: Exp Date: _______/_________ Amount:$ ________________ Name on card: ____________________ Signature: __________________________

Have I completed all components of the Application Form fully ?(Attach Cheque/Money order or pay by Credit Card over phone)

Have I obtained my two Passport photos for ID tags?

Have I sent away my application for National Police check?

Have I obtained a Medical Certificate/letter stating that I am physically fit to bend & lift?

Have I got in order, all the required documents and relevant information copies ready to send my application to Monash University?

Yes – Post application to: Attn: Barbara Martin

Monash University

DCEH&PP

Central & Eastern Clinical School

1^st Floor Alfred Lane, Commercial Road

PRAHRAN VIC 3181

No – Then what do I need to finalise?

MUcaps

Certtificate III Application Form

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