APPLICATION FOR DUPLICATE RECORD OF RESULTS - TISC

TERTIARY INSTITUTIONS SERVICE CENTRE
(Incorporated in Western Australia)
100 Royal Street, East Perth
Western Australia 6004
Telephone (08) 9318 8000
Facsimile (08) 9225 7050
http://www.tisc.edu.au/
APPLICATION FOR RECORD OF RESULTS
CUSTOMER SERVICE STATEMENT
Our goal is to provide records of results within four (4) working days of receiving a completed application
form. TISC takes every effort to protect confidentiality of examination results.
INCLUDE THE FOLLOWING WITH YOUR APPLICATION
1. Proof of Identity eg copy of driver’s licence, proof of age card, passport or birth certificate. If you have no
proof of identity, complete the Proof of Identity section on page three.
2. Change of name documentation (if applicable) eg copy of marriage certificate, deed poll certificate.
3. Payment of $35 (incl. GST) per certificate – see next page for payment by credit card.
APPLICANT DETAILS
FAMILY NAME:
GIVEN NAMES:
FULL NAME AS IT
WILL APPEAR ON
ORIGINAL RECORD:
DATE OF BIRTH:
POSTAL ADDRESS:
TELEPHONE:
EMAIL:
SIGNATURE:
Please leave blank if same as above. If different, also provide proof of name change.
GENDER (M/F):
POSTCODE:
DATE:
DOCUMENT(S) REQUIRED Tick item(s)
required
$35.00 per copy
TAE - Joint Admissions Advice Letter (1975 - 1985)
TEE – Universities’ Admission Advice Letter (1986 - 2008)
WACE - Universities’ Admission Advice Letter (2009 onwards)
ATAA - Alternative Test for Adult Admission (1980 - 1991)
STAT - Special Tertiary Admissions Test (1992 onwards)
WAUFP – Western Australian Universities’ Foundation Program
Results Letter (1996 – 2010; 2013 onwards)
WAUPP – Western Australian Universities’ Preparatory Program
Results Letter (2011 - 2012)
Curtin University· Edith Cowan University · Murdoch University · The University of Western Australia
Year(s)
of examination
See page 2

IDENTIFYING DOCUMENT/S SUBMITTED (please tick)
Photographic ID eg Passport, Driver’s Licence or Proof of Age card
Official Birth Certificate (extract not acceptable)
Witness Statement - using Authorised Witness as described under the Western Australian
Oaths, Affidavits and Statutory Declarations Act 2005 (see page 3)
IF APPLICABLE - Proof of name change eg Marriage Certificate
DOCUMENT(S) COLLECTION/DELIVERY (tick one)
Please post to the address I have provided on this form
I will collect from TISC office on or after ____________________
• Proof of identification will be required when collecting the document(s).
• If another person is to collect the document(s) on your behalf. Please complete:
I authorise
(Name) (Date of birth)
to collect the document on my behalf.
METHOD OF PAYMENT
(Your signature)
Payment is only accepted in Australian dollars. Forms received without payment will be returned unprocessed.
Cash/Eftpos (only available when lodging in person at our office)
Cheque/Money Order (payable to TISC)
Credit Card (see below)
Please charge my Mastercard Visacard
CARDHOLDER NAME (please print):
CARD NUMBER:__ __ __ __ / __ __ __ __ / __ __ __ __ / __ __ __ __ EXPIRY DATE: __ __ / __ __
with the amount of $ __________________ being for _____________ result/s @ $35 per copy.
SIGNATURE OF CARDHOLDER:
NOTE: Should credit card payment be declined your form will be returned unprocessed.
Office use only
Checked ID
DATE:
CheckedManual Photocopied Posted/Collected
Page 2 of 3

NO PROOF OF IDENTITY – WITNESS STATEMENT
If you have no proof of identity, please have the following section completed by someone who is described as
an authorised witness under the Oaths, Affidavits and Statutory Declarations Act 2005 and who is NOT related
to you by birth or marriage. Refer to http://www.courts.dotag.wa.gov.au/W/witnessing_documents.aspx.
WITNESS STATEMENT
I certify that
is known to me and that he/she has signed this form in my presence.
WITNESS SIGNATURE: DATE:
OCCUPATION: REGISTRATION No:
NAME (please print):
STREET
ADDRESS:
SUBURB:
DAYTIME TELEPHONE:
Professions as of January 2012 that can witness statutory declarations are:
• Academic {post-secondary institution}
o Member of academic staff at the Universities
or State Training Providers
• Accountant – member of:
o Association Of Taxation and Management
Accountants
o CPA Australia
o The Institute of Chartered Accountants in
Australia
o Institute of Public Accountants
o National Tax and Accountants’ Association
Ltd
• Architect
o Registered under the Architects Act 2004
• Australian Consular Officer
• Australian Diplomatic Officer
• Bailiff
• Bank Manager
• Chartered secretary
o Member of Chartered Secretaries Australia
Ltd
• Chemist
• Chiropractor
• Company auditor or liquidator
• Court officer {Judge, magistrate, registrar or clerk}
• Defence Force officer
o An officer within the meaning of the Defence
Force Discipline Act 1982
o A non-commissioned officer within the Act
with 5 or more years of continuous service
o A warrant officer within the meaning of the
Act
• Dentist
• Doctor
• Electorate Officer {State – WA only}
• Engineer
o A member of the Institution of Engineers
Australia other than at the grade of student
POSTCODE:
• Industrial organisation secretary
• Insurance broker
o Member of the National Insurance Brokers
Association of Australia
• Justice of the Peace {any State}
• Lawyer
• Local government CEO or deputy CEO
• Local government councillor
• Loss adjuster
o Member of the Australasian Institute of
Chartered Loss Adjusters
• Marriage Celebrant
• Member of Parliament {State or Commonwealth}
• Minister of religion
• Nurse
• Optometrist
• Patent Attorney
• Physiotherapist
• Podiatrist
• Police officer
• Post Officer manager
• Psychologist
• Public Notary
• Public Servant {State or Commonwealth}
• Real Estate agent
o Holder of a licence under the Real Estate
and Business Agents Act 1978
• Settlement agent
o Holder of a licence under the Settlement
Agents Act 1981
• Sheriff or deputy Sheriff
• Surveyor
o Under Licensed Surveyors Act 1909
• Teacher
• Tribunal officer
• Veterinary surgeon
Page 3 of 3