Application Form

Course Application FormFee for Service CoursesPersonal DetailsTitle: Mr / Mrs / Miss / Ms Date of Birth: _____ / _____ / _____Given Name:Surname:Gender: Male Female Home Ph:Work Ph:Mobile:Email:Address:Suburb: State: Postcode:Course DetailsCourse Name:Location:Start Date:Please provide details of your work experience and qualifications.Complete the tables below or attach copies of your resume and qualifications.List any qualifications and/or courses you have successfully completedQualification/Course Name Training Provider Year CompletedAustralian orOverseas?Provide details of your work experiencePositions held Company names Dates© Benchmark College – Sept 2012 Page 1 of 2

Course Application FormFee for Service CoursesOf the following categories, which best describes your main reason for undertaking this course?To get a jobTo develop my existing businessTo try for a different careerFor personal interest or developmentTo get a better job or promotionIt is a requirement of my jobI want extra skills for my jobTo start my own businessTo get into another course of studyOther reasonsIn further detail, list your reasons for undertaking this course.Do you have access to a computer and the Internet for the purposes of completing course assessments? Yes NoHow did you find out about the course? Job Services Australia Provider Benchmark Newsletter Word of Mouth Benchmark Website Newspaper Advertisement Internet Search Employer Other _____________________________PaymentSelect from the list below: I have enclosed a cheque or money order I have paid by direct deposit & emailed the transaction receipt I have completed my credit card details below I will be paying by direct debit instalments.Only available where course fee is over $490.(Fees & charges apply, please contact Accounts for further details)Direct Deposit details:ANZ BankBSB: 012-429 A/C #: 8416-74536A/C Name: Benchmark Resources Pty LtdIf paying by direct deposit, please enter your namein the reference field & email the transactionreceipt to accounts@benchmark.edu.auCredit Card Payment AuthorisationVisa, Bankcard or MasterCardCard Number: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Expiry: ____ / ____ Amount: $_________Name on Card: ___________________________________________________________ Verification Code (last 3 digits): _________Cardholder Signature: ______________________________________________________ Date: ____ / ____ / ____DeclarationI verify that all information is true and correct and I provide consent for this information to be used by Benchmark College for enrolment andauditing purposes.Applicant Signature:Date:PLEASE SUBMIT COMPLETED FORM Fax: 02 4722 3599 Email: info@benchmark.edu.auWITH PAYMENT & IDENTIFICATION Post: PO Box 4098 Penrith NSW 2750In person: 140-142 Henry St (Allen Arcade), Penrith© Benchmark College – Sept 2012 Page 2 of 2