Office Use Only

JAMES COOK UNIVERSITY

DATA No

F M H M S A PPL IC AT ION F OR M 2013 ENTRY DOMESTIC APPLICANTS

Please place a tick in the box next to the degree/s for which you wish to apply.

r Bachelor of Dental Surgery r Bachelor of Medicine, Bachelor of Surgery r Bachelor of Physiotherapy r Bachelor of Veterinary Science
Return application form by 30 September 2012* to the Faculty Student Office, Faculty of Medicine, Health & Molecular Sciences, PO Box 864 Aitkenvale Business Centre, Qld, 4814.
*APPLICATIONS POSTMARKED AFTER THIS DATE WILL NOT BE ACCEPTED.
POSTMARKED MEANS DATE STAMPED BY THE POST OFFICE ON THE DAY THAT YOU POST THE APPLICATION FORM. REGISTERED MAIL IS RECOMMENDED

(Please tick one box only) Dr Mr Mrs Ms Miss Family Name ..................................................................................................................................................................... Date of Birth ___ ___ / ___ ___ / ___ ___ ___ ___
DD MM

Given Names Gender Postal Address

...............................................................................................................................................................................................................................

YYYY

Male

Female

....................................................................................................................................................................................................................................................................................................................................................................

........................................................................................................................................................................................................................................................

Post Code ...............................................................

(Mobile)

Telephone ( Facsimile (

.................................................................................

(AH)

) ....................................................................................... (BH)

.......................................................................................................

) ...............................................................................................

Email Address .................................................................................................................................................................................................................

Are you currently or have you ever been a JCU Student?

Yes

No

(if Yes) JCU ID number __________________

QTAC Application number .........................................................................................................................................................................................................................................................................................................................................

Citizenship Status (please tick one box only): Australian Citizen Australian Permanent Resident Yes 1
Faculty of Medicine, Health & Molecular Sciences, July 2012 CRICOS 00117J

New Zealand Citizen No

Are you of Aboriginal or Torres Strait Islander origin?

INSTRUCTIONS
x Before completing this application please download and read, for each degree you are applying for, the information documents for Domestic Applicants: http://www.jcu.edu.au/fmhms/forms/index.htm x Tick the front page to indicate the degree or degrees that you wish to apply for and complete all sections of the application form. Complete one application only, even if applying for more than one degree. x Ensure you provide the same name and date of birth details to James Cook University as on your application to QTAC. x Complete all sections of this form. Information must be completed in your own handwriting. Failure to complete all appropriate sections may affect your selection. x Applicants applying for both Veterinary Science and other degrees must complete both written components. x Applicants (other than JCU students) must also apply to and comply with the appropriate QTAC application procedures. QTAC http://www.qtac.edu.au x If you are a current student of JCU or have completed at least one Teaching Period (one semester) of study in the last five years, you DO NOT apply to QTAC but submit this application together with a Course Transfer Application and deliver to the Faculty Student Office, Building 39, Demountable Building Medical 1, Townsville Campus or post to the Faculty Student Office, PO Box 864 Aitkenvale Business Centre, Qld, 4814. You are not required to attach a certified copy of your academic record. Course Transfer Application http://www.jcu.edu.au/student/idc/groups/public/documents/form_download/jcudev_007458.pdf x Securely attach supporting documentation (where applicable). Send only certified copies as originals cannot be returned to you. Certified Copy: A photocopy of an original document that has been certified by those listed under "Document Certification Requirements" on page 15 x Only one copy of your application will be accepted. x Return Pages 1-14 of Application. x Enclose a SEALED and STAMPED self-addressed envelope for acknowledgment of receipt of your application. Write the name of the degree/s you are applying for on the back of this envelope. This envelope will be stamped by the Faculty and returned to you. If requesting acknowledgment for documents sent from overseas, including New Zealand, please enclose an International Reply coupon, available from most Post Offices and a self-addressed envelope. x Return application form by 30 September, 2012. Deliver Faculty Student Office, Building 39, Demountable Building Medical 1, Townsville Campus Or Post Faculty Student Office, PO Box 864 , Aitkenvale Business Centre, Qld 4814 x To ensure your application arrives safely and on time we suggest you use Registered Mail and request the Post Office to date stamp the envelope.

Faxed copies of the application and any documentation sent separately will not be accepted.
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Faculty of Medicine, Health & Molecular Sciences, July 2012 CRICOS 00117J

Please indicate which best describes your HIGHEST level of education to date.

PLEASE TICK ONLY ONE OF THE FOLLOWING

Currently studying Year 12 or equivalent (studying Year 12 in 2012) Completed Year 12 or equivalent (prior to 2012).
Please indicate the year you completed year 12 or equivalent:

Completed TAFE qualifications:

Advanced Diploma Diploma Certificate IV Certificate III

Currently studying a tertiary degree:

How many years will you have completed by the end of 2012? years (Please complete the Table on page 5)

Completed a tertiary degree:

What level of tertiary study have you completed? Undergraduate Postgraduate Coursework Postgraduate Research Please indicate the year you completed your most recent level of tertiary study: (Please complete the Table on page 5)

Commenced a tertiary degree but not currently enrolled

Please indicate your most recent year of enrolment: (Please complete the Table on page 5)

If none of the above apply to you:

(complete the section below and indicate in detail your qualifications) (a) the institution you are studying at or have studied with; (b) the level of qualification you have obtained or are studying; and (c) how many years study you will have completed of this course at the end of this year. Name of Institution Qualification or Course Completed Yes/No Year Completed OR Most Recent Year of Enrolment

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Faculty of Medicine, Health & Molecular Sciences July 2012 CRICOS 00117J

PLEASE DETAIL ALL SCHOOLS ATTENDED FROM YEAR 1 TO COMPLETION OF YOUR SECONDARY EDUCATION. List each year on a seperate line as indicated in the example below. If you have completed part or all of your schooling overseas please complete as per the example on line 2 below. This section must be completed as per example. List all primary and secondary schools attended by year.
Year Grade School Name Suburb Town/City State Post Code
4870 4870
OFFICE USE

eg. 1986 1987 1988

1 2 3

Trinity Bay Primary Trinity Bay Primary Overseas

Edgehill Edgehill England

Cairns Cairns

Qld Qld

If you have not commenced tertiary studies and completed Year 12 or equivalent prior to 2012, what have you been doing? Work Travel Exchange program (ie Rotary) Other (provide a brief outline below)

__________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________

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Faculty of Medicine, Health & Molecular Sciences, July 2012 CRICOS 00117J

PLEASE LIST ANY TERTIARY STUDIES YOU HAVE ATTEMPTED OR COMPLETED. Undergraduate and Postgraduate Tertiary Studies DO NOT include Bridging Courses

Name of Institution

Qualification or Course

Completed Yes/No

Year Completed OR Most Recent Year of Enrolment

2005

eg. CQ University

BSc

Yes

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Faculty of Medicine, Health & Molecular Sciences, July 2012 CRICOS 00117J

PLEASE NOTE THAT YOU MUST COMPLETE THE STATUTORY DECLARATION SET OUT BELOW AND HAVE IT WITNESSED

DECLARATION: I declare that to the best of my knowledge the information on this form is correct and complete. I acknowledge that the withholding of any information relating to the provision of incorrect information may result in the withdrawal of a place that may be offered, and, that this withdrawal may take place at any stage during the course.

Signature of applicant

........................................................................................................................................................................................................

Date ................................................................................................................................

Taken and declared before me, at ............................................................................................................................................................................................................................................................................................................................. This day of 2012.

...........................................................................................................................................................................................

...................................................................................................................................................................................

..............................................................................................................................................................................................................................................................................................................................

A Justice of the Peace/Commissioner of Declarations or equivalent (as listed under Document Certification Requirements on page 15)

PRIVACY STATEMENT PLEASE NOTE: Information contained on this form is collected for selection and administrative purposes. Personal information will not be passed on to any other external bodies without your authorisation unless a valid legal request has been made.

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Faculty of Medicine, Health & Molecular Sciences, July 2012 CRICOS 00117J

Office Use Only

JAMES COOK UNIVERSITY

DATA No

FMHMS APPLICATION FORM 2 0 1 3 D O M E S T I C E N T R Y A P P L I C A N T S

BACHELOR OF DENTAL SURGERY BACHELOR OF MEDICINE, BACHELOR OF SURGERY BACHELOR OF PHYSIOTHERAPY

W R I T T E N

C O M P O N E N T

PLEASE COMPLETE THE FOLLOWING IN YOUR OWN HANDWRITING

(Please tick one box only) Dr Given Names Gender Mr Mrs Ms Miss Family Name ..................................................................................................................................................................... Date of Birth ___ ___ / ___ ___ / ___ ___ ___ ___
DD MM YY

...............................................................................................................................................................................................................................

Male

Female

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Faculty of Medicine, Health & Molecular Sciences, July 2012 CRICOS 00117J

Please complete the remaining sections of this form in your own handwriting in black or blue ink. Either cursive or print is acceptable (computer generated responses will not be accepted). PLEASE ANSWER THE FOLLOWING QUESTION WITHIN THE LINE SPACE PROVIDED.
1. Why do you want to become a medical practitioner / health professional?

PLEASE ANSWER THE FOLLOWING QUESTION WITHIN THE LINE SPACE PROVIDED.
2. Tell us why you are interested in enrolling in a course where important themes are rural, remote, Indigenous and tropical health and medicine?

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Faculty of Medicine, Health & Molecular Sciences, July 2012 CRICOS 00117J

PLEASE ANSWER THE FOLLOWING QUESTION WITHIN THE LINE SPACE PROVIDED.
3. What activities (paid employment, work experience or voluntary) have you undertaken, in addition to your studies, which indicate your motivation to study medicine or another health professional degree at James Cook University?

PLEASE ANSWER THE FOLLOWING QUESTION WITHIN THE LINE SPACE PROVIDED.
4. Provide any other information you believe is relevant to your application.

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Faculty of Medicine, Health & Molecular Sciences, July 2012 CRICOS 00117J

PLEASE ATTACH LETTERS OF SUPPORT HERE

You may attach up to three letters of support to your application (this is not compulsory). If you choose to attach letters of support, make sure to ask your referees to include their phone number in case we need to contact them. You must keep a copy of any letters of support (and your completed application) as no documentation can be returned to you. Only the first three (3) letters of support will be read. Do not send letters of support separately as they will not be included as part of your application. Letters of support from family members will not be accepted.

LETTERS OF SUPPORT

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Faculty of Medicine, Health & Molecular Sciences, July 2012 CRICOS 00117J

Office Use Only

JAMES COOK UNIVERSITY

DATA No

FMHMS APPLICATION FORM 2 0 1 3 E N T RY D O M E S T I C A P P L I C A N T S

BACHELOR OF VETERINARY SCIENCE

W R I T T E N

C O M P O N E N T

PLEASE COMPLETE THE FOLLOWING IN YOUR OWN HANDWRITING

(Please tick one box only) Dr Given Names Gender Mr Mrs Ms Miss Family Name ..................................................................................................................................................................... Date of Birth ___ ___ / ___ ___ / ___ ___ ___ ___
DD MM YY

...............................................................................................................................................................................................................................

Male

Female

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Faculty of Medicine, Health & Molecular Sciences, July 2012 CRICOS 00117J

Please complete the form neatly in your own handwriting in black or blue ink. Either cursive or print is acceptable (computer generated responses will not be accepted). PLEASE ANSWER THE FOLLOWING QUESTION WITHIN THE LINE SPACE PROVIDED.
1. Why do you wish to pursue a career in Veterinary Science?

PLEASE ANSWER THE FOLLOWING QUESTION WITHIN THE LINE SPACE PROVIDED.
2. What activities (paid employment, work experience or voluntary) have you undertaken, in addition to your studies, which indicate your motivation to study Veterinary Science?

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Faculty of Medicine, Health & Molecular Sciences, July 2012 CRICOS 00117J

PLEASE ANSWER THE FOLLOWING QUESTION WITHIN THE LINE SPACE PROVIDED.
3. Tell us why you are interested in enrolling in a veterinary science course which has a strong focus on rural, regional and tropical practice.

PLEASE ANSWER THE FOLLOWING QUESTION WITHIN THE LINE SPACE PROVIDED.
4. Is there any other information you believe is relevant to your application?

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Faculty of Medicine, Health & Molecular Sciences, July 2012 CRICOS 00117J

PLEASE ATTACH LETTERS OF SUPPORT HERE

You may attach up to three letters of support to your application. If you choose to attach letters of support, make sure to ask your referees to include their phone number in case we need to contact them. You must keep a copy of any letters of support (and your completed application) as no documentation can be returned to you. Only the first three (3) letters of support will be read. Do not send letters of support separately as they will not be included as part of your application. Letters of support from family members will not be accepted.

LETTERS OF SUPPORT

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Faculty of Medicine, Health & Molecular Sciences, July 2012 CRICOS 00117J

DO NOT RETURN THIS PAGE

APPLICATION CHECKLIST 2013 ENTRY
HAVE YOU: Applied to QTAC by 28 September 2012 and/or JCU by the closing date of 30 September 2012? Completed all sections of the application form (where applicable)? Written your JCU student number on the application form (if applicable)? Used the same name and date of birth on the FMHMS Application Form as was provided to QTAC (if applicable)? Completed your application form and the appropriate written component neatly, in your own hand writing using black or blue ink in either cursive or print (computer generated responses will not be accepted)? Attached a Course Transfer Application (JCU students only)? Read and signed the Declaration in the presence of the person witnessing your application? Enclosed a SEALED and STAMPED self-addressed envelope for acknowledgment of receipt of your application? Write the name of the degree/s you are applying for on the back of this envelope (This envelope will be stamped by the Faculty and returned to you). If requesting acknowledgment for documents sent from overseas (including New Zealand), please enclose an International Reply coupon, available from most Post Offices and a self-addressed envelope. Kept a photocopy of this application for your records?

DOCUMENT CERTIFICATION REQUIREMENTS

When preparing your application to James Cook University, it is essential that you supply correct and complete supporting documentation. Failure to do so may affect your selection. You must submit certified copies of documentation (where requested) with your application. Uncertified copies, and photocopies of certified copies are not permissible. James Cook University will accept copies certified by: x A Justice of the Peace (JP) x A Commissioner of Declarations x A Barrister, Solicitor, Pharmacist, Medical Practitioner x The University Admission Centre of any Australian state e.g. QTAC, VTAC, UAC x An Australian overseas diplomatic mission x A Police Officer at, or above the rank of Sergeant x Current School Principal The person certifying photocopies of original documentation must state "I certify this to be a true copy of the original which I have sighted at the time of signing", provide their signature, occupation and telephone number and affix the official stamp or seal of their organisation, if available, on the front of each copy. Please note that it is your responsibility to ensure that your application is complete at the time of submission. Qualifications/other documentation written in a language other than English: Please provide certified translations and a certified copy of the original documentation.

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Faculty of Medicine, Health & Molecular Sciences, July 2012 CRICOS 00117J