Expression of interest for RII60415

Salutation:   Mr   Mrs   Miss   Ms
Surname:

First Name:

Middle Names:

Preferred Name:

Gender:
Date of Birth: //
Address:

State:

Postcode:

E-mail:

Phone:

Fax:

Mobile:

Have you previously completed study with Australasian Drilling Institute?  Yes  No

Preferred delivery style:
 Blended     RPL     GAP Training   

Employment:
Of the following categories, which best describes your Employment Status?

 Full Time  Part Time
 Self Employed  Employer
 Unemployed Seeking Full time Work  Unemployed Seeking Part time Work
 Not employed - Not seeking employment  Employed - unpaid family worker

Study Reason:
What is your reason for wanting to complete this Course?

It was a requirement of my job I wanted extra skills for my job
To get into another course of study To get a better job or promotion
To try for a different career To start my own business
To develop my existing business Other Reasons
For personal interest or self development  

Schooling:
What is your highest completed School Level:

  Year 12     Year 11     Year 10     Year 9     Year 8 or below

Previous Educational Achievements:
Since leaving school have you successfully completed any other qualifications? Yes  No
If Yes, what is your highest completed achievement:

Bachelor or Higher Advanced Diploma Diploma
 Cert IV  Cert III  Cert II
 Cert I  Certificate  

Cultural Diversity:

Were you born in Australia? Yes No
If No, in which country were you born? 

Do you identify yourself as any of the following:

 Aboriginal     Torres Strait Islander     South Sea Islander   

Language:

Do you speak a language other than English at home?  Yes     No (English Only)
If yes, please specify the main language spoken at home?
How well do you speak English?
 Very Well     Well     Not Well     Not at all
Is English language assistance required (including reading and/or writing)?   Yes     No

Medical Conditions/Disability:

Do you consider yourself to have a disability, impairment or long term condition? 
 Yes    No

If Yes, please tick ANY applicable boxes:

 Hearing/Deaf  Learning  Vision
 Physical  Mental  Medical Condition
 Intellectual  Acquired Brain Impairment  Other


Licences:

Please list any Licences you currently hold e.g. Car, HR, Forklift, Traffic Controller, the Class of licence and expiry date.




Emergency Contact:
Name:

Address:

Phone:

Relationship:

By checking this box you are agreeing to the Terms & Agreement and state the details entered are true and correct.

Signature:
Date: