COURSE APPLICATION/ENROLMENT FORM
PLEASE USE BLOCK LETTERS AND COMPLETE ALL SECTIONS
All Applicants: Please complete both sides and return this form to the relevant branch
This Section DECA Training Use Only: Exempt Code: Project No.:
Course Type Vehicle Type: Duration: (Hrs) Start Date: Course Type Vehicle Type: Duration: (Hrs) Start Date:
Section 1 – Personal Details
Mr/Mrs/Miss Surname Given Names
Postal Address
City/Suburb Email:
What is the Postcode of the Suburb or Town in which you usually live?
Telephone: BH AH MOBILE
Sex: Female Male Enter your date of Birth: Day Month Year of Birth
Section 2 – Education What is your highest COMPLETED school level? (Tick one box only)
12 Year 12 11 Year 11 10 Year 10 9 Year 9 8 Year 8
02 Did not go to school Are you still attending secondary school? Yes No
In which year did you complete that school level?
Section 3 – Employment Of the following categories, which BEST describes your current employment status? (Tick one box only)
01 Full Time Employee 02 Part-time Employee 03 Self-Employed Not employing others
04 Employer 05 Employed - unpaid worker in family business 06 Unemployed - Seeking fulltime work
07 Unemployed - seeking part-time work 08 Not employed - not seeking employment
Section 4 – Further Education
Have you SUCCESSFULLY completed any of the following qualifications? Yes No If yes, then tick ANY applicable boxes
008 Bachelor Degree or Higher Degree 511 Certificate IV (or Advanced Certificate/Technician)
410 Advanced Diploma or Associate Degree 514 Certificate III (or Trade Certificate) 524 Certificate I
420 Diploma (or Associate Diploma) 521 Certificate II 990 Certificates other than listed
Section 5 – Are you of Aboriginal or Torres Strait Islander Origin? 4 No
1 Yes, Aboriginal 2 Yes, Torres Strait Islander 3 Yes, Aboriginal and Torres Strait Islander
Section 6 – Do you consider yourself to have a disability, impairment or long term condition? Yes No
If yes, then indicate the areas of the disability, impairment or long term condition (You may indicate more than one area)
11 Hearing/Deaf 12 Physical 13 Intellectual 14 Learning 15 Mental Illness
16 Acquired Brain Impairment 17 Vision 18 Medical Condition 19 Other
Section 7 – In which Country were you born?
Australia Other Please specify
Section 8 – Languages
Do you speak a language other than English at home? (If you speak more than 1 language, indicate the one that is spoken most often)
No English only Yes. Other Please specify
How well do you speak English? 1 Very Well 2 Well 3 Not Well 4 Not at all
Section 9 – Study Reason
Of the following categories, which BEST describes your main reason for undertaking this Course/Traineeship/Apprenticeship? Tick one only.
01 To get a job 02 To develop my existing business 03 To start my own business
04 To try for a different career 05 To get a better job or promotion 06 It was a requirement of my job
07 I wanted extra skills for my job 08 To get into another course of study 11 Other reasons
12 For personal interest or self development
Enrol/Applic Form Page 1 of 2
Effective Date 1 May 2007
33078 Enrolment - Course Applica1 1
COURSE APPLICATION/ENROLMENT FORM
PLEASE USE BLOCK LETTERS AND COMPLETE ALL SECTIONS
All Applicants: Please complete both sides and return this form to the relevant branch
This Section DECA Training Use Only: Exempt Code: Project No.:
Section 1 – Personal Details
Mr/Mrs/Miss Surname Given Names
Postal Address
City/Suburb Email:
What is the Postcode of the Suburb or Town in which you usually live?
Telephone: BH AH MOBILE
Sex: Female Male Enter your date of Birth: Day Month Year of Birth
Section 2 – Education What is your highest COMPLETED school level? (Tick one box only)
12 Year 12 11 Year 11 10 Year 10 9 Year 9 8 Year 8
02 Did not go to school Are you still attending secondary school? Yes No
In which year did you complete that school level?
Section 3 – Employment Of the following categories, which BEST describes your current employment status? (Tick one box only)
01 Full Time Employee 02 Part-time Employee 03 Self-Employed Not employing others
04 Employer 05 Employed - unpaid worker in family business 06 Unemployed - Seeking fulltime work
07 Unemployed - seeking part-time work 08 Not employed - not seeking employment
Section 4 – Further Education
Have you SUCCESSFULLY completed any of the following qualifications? Yes No If yes, then tick ANY applicable boxes
008 Bachelor Degree or Higher Degree 511 Certificate IV (or Advanced Certificate/Technician)
410 Advanced Diploma or Associate Degree 514 Certificate III (or Trade Certificate) 524 Certificate I
420 Diploma (or Associate Diploma) 521 Certificate II 990 Certificates other than listed
Section 5 – Are you of Aboriginal or Torres Strait Islander Origin? 4 No
1 Yes, Aboriginal 2 Yes, Torres Strait Islander 3 Yes, Aboriginal and Torres Strait Islander
Section 6 – Do you consider yourself to have a disability, impairment or long term condition? Yes No
If yes, then indicate the areas of the disability, impairment or long term condition (You may indicate more than one area)
11 Hearing/Deaf 12 Physical 13 Intellectual 14 Learning 15 Mental Illness
16 Acquired Brain Impairment 17 Vision 18 Medical Condition 19 Other
Section 7 – In which Country were you born?
Australia Other Please specify
Section 8 – Languages
Do you speak a language other than English at home? (If you speak more than 1 language, indicate the one that is spoken most often)
No English only Yes. Other Please specify
How well do you speak English? 1 Very Well 2 Well 3 Not Well 4 Not at all
Section 9 – Study Reason
Of the following categories, which BEST describes your main reason for undertaking this Course/Traineeship/Apprenticeship? Tick one only.
01 To get a job 02 To develop my existing business 03 To start my own business
04 To try for a different career 05 To get a better job or promotion 06 It was a requirement of my job
07 I wanted extra skills for my job 08 To get into another course of study 11 Other reasons
12 For personal interest or self development
Enrol/Applic Form Page 1 of 2
Effective Date 1 May 2007
17/04/2007 2:01:44 PM
17/04/2007 2:01:45 PM 33078 Enrolment - Course Applica2 2

Section 10 – Licence Details Section 10 – Licence Details

I declare that I am the holder of a current driver’s licence Signed:
Driver’s Licence No.: Licence Expiry Date:
State of Issue: No. of years Licence held for:
Licence Type/s (Class)
Years of driving experience: Motorbike Car Bus Truck
I declare that I am the holder of a current driver’s licence Signed:
Driver’s Licence No.: Licence Expiry Date:
State of Issue: No. of years Licence held for:
Licence Type/s (Class)
Years of driving experience: Motorbike Car Bus Truck

Is your Driver’s Licence subject to a Probationary / Provisional Period? Yes No Is your Driver’s Licence subject to a Probationary / Provisional Period? Yes No

If Yes, what is the Probationary/Provisional Period Expiry Date?: If Yes, what is the Probationary/Provisional Period Expiry Date?:

Section 11 – Employer Name (Please supply if course is employer sponsored) Section 11 – Employer Name (Please supply if course is employer sponsored)

Section 12 - Course Details Section 12 - Course Details

ALL APPLICANTS FOR TRUCK LICENCE OR MOTORCYCLE LEARNER / LICENCE COURSES MUST COMPLETE THE FOLLOWING ALL APPLICANTS FOR TRUCK LICENCE OR MOTORCYCLE LEARNER / LICENCE COURSES MUST COMPLETE THE FOLLOWING
HEALTH DECLARATION: HEALTH DECLARATION:
Your Health Details Your Health Details
(a) Have you ever suffered from bad eyesight or hearing, dizziness, blackouts, epilepsy, diabetes, psychiatric or mental illness OR any (a) Have you ever suffered from bad eyesight or hearing, dizziness, blackouts, epilepsy, diabetes, psychiatric or mental illness OR any
other medical conditions or other disability which may affect your driving? Yes No other medical conditions or other disability which may affect your driving? Yes No
(b) Are you taking any drugs or prescribed medication? Yes No (b) Are you taking any drugs or prescribed medication? Yes No
If you answered YES to either of the above questions, please provide details: If you answered YES to either of the above questions, please provide details:

If you have answered YES to either of the above questions, a clearance from your State Regulatory Authority Medical Review If you have answered YES to either of the above questions, a clearance from your State Regulatory Authority Medical Review
Board will be required before training can commence. The only exceptions are prescription glasses or asthma treated by puffer. Board will be required before training can commence. The only exceptions are prescription glasses or asthma treated by puffer.

Course Name Course Date Course Fee Course Name Course Date Course Fee

PAYMENT IS REQUIRED IN FULL TO CONFIRM YOUR BOOKING PAYMENT IS REQUIRED IN FULL TO CONFIRM YOUR BOOKING
Payment Enclosed: OR Charge to Existing Account: OR Credit Card: Payment Enclosed: OR Charge to Existing Account: OR Credit Card:

VISA MASTERCARD AMERICAN EXPRESS Card Number: VISA MASTERCARD AMERICAN EXPRESS Card Number:

Expiry Date: / Name on Card: Signature of Cardholder: Expiry Date: / Name on Card: Signature of Cardholder:
COURSE REFUNDS & CANCELLATION POLICY – Full payment required fourteen (14) days prior to course. (Note: except where credit facilities have been granted) COURSE REFUNDS & CANCELLATION POLICY – Full payment required fourteen (14) days prior to course. (Note: except where credit facilities have been granted)
1. Two weeks notice or more: No charge. 2. Cancellation within fourteen (14) days or failure to attend will incur forfeiture of full payment. 3. Clients with credit facilities will be invoiced in accordance 1. Two weeks notice or more: No charge. 2. Cancellation within fourteen (14) days or failure to attend will incur forfeiture of full payment. 3. Clients with credit facilities will be invoiced in accordance
with the above policy. 4. Alterations to booking dates or transfers to a different course cannot be made within fourteen (14) days of the course commencement date. with the above policy. 4. Alterations to booking dates or transfers to a different course cannot be made within fourteen (14) days of the course commencement date.

Client Declaration Client Declaration

I declare that I do hold the pre-requisite Driver Licence to attend my chosen DECA Training course. I authorise the Trainer and/or DECA Training to release information regarding my I declare that I do hold the pre-requisite Driver Licence to attend my chosen DECA Training course. I authorise the Trainer and/or DECA Training to release information regarding my
enrolment, and assessment outcomes to government departments and to other parties where DECA Training is legally obliged to do so, or where it is required as evidence of assessment. I enrolment, and assessment outcomes to government departments and to other parties where DECA Training is legally obliged to do so, or where it is required as evidence of assessment. I
acknowledge that I have received the DECA Training “Essential Information for Course Participants” leaflet and agree to comply with DECA Training policies listed in that document. acknowledge that I have received the DECA Training “Essential Information for Course Participants” leaflet and agree to comply with DECA Training policies listed in that document.

Client’s Signature: Date: / / Client’s Signature: Date: / /

DECA Training Employee: Date: / / DECA Training Employee: Date: / /

Name Signature Enrol/Applic Form Page 2 of 2
Name Signature Enrol/Applic Form Page 2 of 2
Effective Date 1 May 2007 Effective Date 1 May 2007