DDS Guaranteed pathway application form - Melbourne Dental School

Doctor of Dental Surgery Australian Student ApplicationMelbourne Dental SchoolFaculty of Medicine, Dentistry and Health SciencesAUSTRALIAN STUDENT APPLICATION FORMFOR USE BY APPLICANTS ELIGIBLE FOR GUARANTEED ENTRY ONLYDOCTOR OF DENTAL SURGERYApplication deadline: 5pm Thursday, 30 May 2013The University has set in place a guaranteed entry policy for high-achieving school leavers considering progressing to a graduate professional entrydegree. Information about the guaranteed entry policy is available at: www.futurestudents.unimelb.edu.au/ugrad/apply/scores/guaranteed-entryPlease note this form is only for applicants eligible for guaranteed entry to the Doctor of Dental Surgery, for other course applications please refer tothe MDHS Student Centre website: www.sc.mdhs.unimelb.edu.auPART A: Personal Details (Please fill in all fields)Section A1: Applicant detailsUniversity of Melbourne student number……………………..Title: Dr / Mr / Mrs / Ms / Miss / Other………………………………Family Name:………………………………………………………..Given Name(s):………………………………………………………Former Name* (If applicable):…………………………………………*If your name differs from that on any of your supporting documentation, you must provide certified proof of that change (ie.deed poll or marriage certificate)Date of Birth:……………………………………..(Day, Month, Year)Gender: Female / Male (please circle)Are you an Aboriginal or Torres Strait Islander? Yes / No (please circle)Section A2: Cultural Details (please indicate your citizenship and residency details)Please indicate your citizenship status:□ Australian citizen□ New Zealand citizen□ Australian permanent resident: Please provide your country of birth ………………………, your year of entry intoAustralia (if applicable)……..., and main language spoken at home…………………………………….□ Permanent humanitarian visa holder: Please provide your country of birth …..………………, your year of entry intoAustralia (if applicable)……..., and main language spoken at home…………………………………….If none of the options for citizenship above apply to you then you are an international student. International students must applythrough the University of Melbourne International Admissions Office at:http://www.futurestudents.unimelb.edu.au/admissions/applications/graduate-internationalProof of CitizenshipThe University of Melbourne. CRICOS Provider code: 00116K

Applicants who receive an offer and enrol at the University of Melbourne are required to provide proof of citizenship. Australiancitizens will need to provide details of either an Australian birth certificate, passport or certificate of citizenship. Australianpermanent residents will require their visa details and New Zealand citizens will require their New Zealand passport.Section A3: Address detailsPermanent Address (required):……………………………………………………………………............State……………Postcode…………Country:………………………………………….Postal address (if different from your permanent address):……………………………………………………………………............State……………Postcode…………Country:………………………………………….Contact DetailsTelephone: ............ ..................................................... Mobile phone: ...............................................................................Facsimile:.....................................................................Email address:...............................................................................PART B Graduate Program by Coursework Fee TypePlease indicate whether you are eligible to be considered for guaranteed entry to a:□ Commonwealth Supported Place (check the eligibility criteria http://futurestudents.unimelb.edu.au/admissions/pathways/guaranteedentry/frequently_asked_questions_about_guaranteed_pathways□ Australian Fee Place (check the eligibility criteria at http://futurestudents.unimelb.edu.au/admissions/pathways/guaranteedentry/frequently_asked_questions_about_guaranteed_pathwaysPART C Academic QualificationsPlease note that Advanced Standing will not be awarded to applicants for the Doctor of Dental Surgery.Section C1Please note, as a current University of Melbourne student, provided you give your student number under which you studied, it isnot necessary for you to supply official or original copies of transcripts from the University of Melbourne. Please attachcertified copies of your academic transcripts for any other tertiary studies that you may have completed.Previous Tertiary StudiesPlease list below University of Melbourne Studies completed.Please complete the table belowName of Qualification:Course Length(No. of years fulltime study)DateCommencedDate of Completion(Or expected tocomplete)Eg. Bachelor of Biomedicine 3 yrs March 2011 December 2013The University of Melbourne. CRICOS Provider code: 00116K

Section C2Prerequisite SubjectsThe Doctor of Dental Surgery requires successful completion of prerequisite University subjects at Level 2 in:Anatomy (one subject); Physiology (one subject); Biochemistry (one subject)* Please provide details below for prerequisite subjects and attach academic transcripts if studies were not completed at theUniversity of MelbourneSubject Name:Eg. Molecular & CellularBiomedicineSubjectCode:Name of Institution:Result:YearCompleted:BIOM20001 University of Melbourne 79 2012PART D How did you find out about the course?For planning purposes we would be grateful if you could let us know how you found out about the course (please nominate amaximum of three by ticking the boxes - listing the most influential information sources if more than three apply).I am a current or previous student of the University of Melbourne□ Graduates of the University of Melbourne□ Advertisement in newspaper/magazine. Please specify ............................................................................................□ Family/friends□ University of Melbourne representative□ University careers adviser/lecturer□ University of Melbourne De website□ Other website: .............................................................................................□ Education exhibition. Location: .............................................................................................□ Other .............................................................................................The University of Melbourne. CRICOS Provider code: 00116K

PART E Declaration and Signature1. I declare that all the information I have submitted with this application is true and complete including:• All the records of the academic results I have achieved at each and every university or tertiary institution I have attended.2. I hereby authorise the University of Melbourne (University) in its absolute discretion to make any enquiries, includingobtaining official records from any education institution or tertiary admissions centre concerning my current or previousacademic results, it believes are necessary.3. I acknowledge that the failure to disclose my true and complete academic record may result in my being excluded from theUniversity. I understand that in investigating the veracity of the information I have provided, the University of Melbournemay require me to repeat the biometric component of any English language proficiency test I have undertaken.4. If I have misrepresented my past and/or present circumstances I acknowledge that the University may terminate my studiesand that the University may terminate my studies at any stage during the course undertaken.5. I understand that the University reserves the right to inform other education institutions if any of the material presented tosupport my application is found to be false or misleading.6. I understand that if I am awarded a scholarship from the University I must not hold another equivalent award at the sametime from the University or any other organisation. If I am awarded a scholarship from the University which is based on falseor misleading information I have provided in my application (or subsequently), I will be required to repay to the Universityany scholarship/s that I have received. Scholarship benefits include living allowances, fee remission and travel allowances.7. I agree to be bound by and comply with by the University’s policy (as amended from time to time) on admission, feespayments and fees refunds outlined in Arrangements Relating to the Payment of Student Fees:www.futurestudents.unimelb.edu.au/int/fees/policy/ options8. I understand that the personal information that I have provided in my application (or subsequently) may be released:• To Australian Commonwealth and State agencies under the Education Services for Overseas Students (ESOS) Act 2000;• To the Department of Education, Employment and Workplace Relations (DEEWR) and that DEEWR will collect and storemy personal information in the Higher Education Information Management System; or• As required to be disclosed by law.9. I acknowledge that all documents submitted become the property of the University of Melbourne and will not be returned.Name of applicant (please print):......................................................................................................................................................................Signature:.................................................................................................Day ........... Month ............Year ...........Please note, unsigned applications cannot be processed.Checklist for Applications (Please tick if applicable)□ All sections have been completed, and relevant questions answered in full□ Evidence of change of name is attached (if applicable)□ For non University of Melbourne pre requisite subjects, evidence of pre requisite subjects completed are attached□ Graduate Access Melbourne application form completed and attached (if applicable)□ The declaration has been signed and datedPlease return completed application form and attachments to:The University of MelbourneMDHS Student CentreLevel 1, Brownless Biomedical LibraryBuilding 182Vic 3010AustraliaEmail enquiries and frequently asked questions to: sc-mdhs@unimelb.edu.auOr visit our website at: : http://www.sc.mdhs.unimelb.edu.au/The University of Melbourne. CRICOS Provider code: 00116K

University of Melbourne privacy statementPrivacy legislationThe University of Melbourne has a statutory obligation to comply with the Information Privacy Act 2000 (VIC) and the HealthRecords Act 2001 (VIC) when collecting, using or handling personal information or health information (“information”).What we collect and whyThe University collects information about a student for a number of purposes. In the main, such purposes relate to the properadministration of an individual's course of study at the University, the University’s internal planning requirements, and theorganisation of relevant health and welfare programs. Student information is also collected for the purposes of fostering alumnirelations and promoting University activities and under Commonwealth or State Government legislation for the purposes ofgovernment reporting and for the administration of, but not limited to, the Higher Education Loan Programme (HEL P) and the YouthAllowance (Austudy and Abstudy). The University will collect information directly from the student him or herself whereverpossible.Accuracy, security and storage of informationThe University holds information in both computer, and paper based records. It takes all reasonable steps to ensure that theinformation it holds is accurate and complete and that it is protected from misuse, loss, unauthorised access or disclosure.Use and disclosure of informationThe Office of the Provost is responsible for maintaining the information of currently enrolled students.The University will not use or disclose your information for purposes other than that for which it was collected, or for related purposewhich you might reasonably expect, without your permission, unless it is permitted or required to do so by law.The University will not release any information it holds about you, including results, addresses or other information, to your relatives(including parents or spouse), without your consent. The University will not confirm that you are or have been a student of theUniversity, except as outlined in this statement, unless you have a record of graduation, as that is a public document.The following are examples of instances where the University may be required by law or permitted to disclose your information: providing information to Centrelink; releasing statistical information to relevant government bodies such as the Department of Education, Employment andWorkplace Relations (DEEWR) and the Office of Training and Tertiary Education; releasing relevant information to the Department of Immigration and Citizenship (DIAC), the Department of Education,Employment and Workplace Relations (DEEWR) and the Australian Taxation Office; providing information to the police where required by law; releasing your academic details to another tertiary institution or tertiary admission centre if you apply to transfer studies; providing a list of enrolled students to the returning officer or other appointed electoral bodies to enable students who wishto vote at elections for student organizations or student representatives to Council to be able to do so (but not for the purposeof contacting students for marketing or promotional purposes); releasing the names of recipients of prizes, scholarships or similar awards to the respective official student sponsors orscholarship providers; providing information in response to a subpoena or summons or a written demand from a government authority with thepower to demand the information; protecting a student or someone else from a serious and imminent threat to their life or health releasing examination results, academic and administrative information, to another institution where the student is enrolledunder an official student exchange, cross-institutional study, dual degree, shared teaching, industry or clinical experience ormulti-institutional arrangement with that institution to facilitate the collaboration or arrangement; publishing examination results; and releasing to another tertiary institution or a tertiary admissions centre, information about a student’s academic progress atthis University and Research Training Scheme entitlement where relevant if a student applies to transfer to that other tertiaryinstitution. On graduation from the University, students become University Alumni. The University (or external partiesappointed by the University) will contact alumni for purposes which include alumni networking, providing graduates withservices and event information through the University’s Advancement Office.The University of Melbourne. CRICOS Provider code: 00116K

Access to personal informationAccess to and correction of your information are handled in accordance with the Freedom of Information Act 1982 (Vic). Dataobtained via the Enrolment Questionnaire that is reported to the Commonwealth Government can be viewed (and, if necessary,corrected) at http://sis.unimelb.edu.au.University Privacy Officer/Privacy policyThe University's Privacy Officer is the University Secretary, Dr Christopher Stewardson. The Privacy Officer's website,www.unimelb.edu.au/unisec/privacy/, contains the University's Privacy Policy and provides detailed information about the contactdetails, complaints procedures and other aspects of the University's privacy regime.QuestionsIf you have an enquiry about your privacy rights in relation to the collection of information from students, please contact theUniversity's Privacy Officer.Authorised by: Faculty General Manager, MDHS, April 2013Published by: MDHS, April 2013Copyright: The University of Melbourne, April 2013INTELLECTUAL PROPERTYFor further information refer to:www.unimelb.edu.au/Statutes/COPYRIGHT IN THIS PUBLICATION ISOWNED BY THE UNIVERSITY AND NOPART OF IT MAY BE REPRODUCEDWITHOUT THE PERMISSION OF THEUNIVERSITY.CRICOS PROVIDER CODE: 00116KDISCLAIMERThe University has used its bestendeavours to ensure that materialcontained in this publication was correctat the time of printing. The Universitygives no warranty and accepts noresponsibility for the accuracy orcompleteness of information and theUniversity reserves the right to makechanges without notice at any time in itsabsolute discretion.STATEMENT ON PRIVACY POLICYWhen dealing with personal or healthinformation about individuals, theUniversity of Melbourne is obliged tocomply with the Information Privacy Act2000 and the Health Records Act 2001.For further information refer to:www.unimelb.edu.au/unisec/privacywww.futurestudents.unimelb.edu.au/gradThe University of Melbourne. CRICOS Provider code: 00116K