Jcudev 013758

Office Use Only
JAMES COOK UNIVERSITY
DATA No
A P P L I C A T I O N
2 0 1 2 E N T R Y
Please place a tick in the box next to the degree/s for which you wish to apply.
r
r
r
r
r
Bachelor of Dental Surgery

Bachelor of Medicine, Bachelor of Surgery
Bachelor of Pharmacy
Bachelor of Physiotherapy
Bachelor of Veterinary Science
Return application form by 30 September 2011*
to the Faculty Student Officer, Faculty of Medicine, Health &Molecular Sciences,
PO Box 864 Aitkenvale Business Centre, Qld, 4814.
*APPLICATIONS POSTMARKED AFTER THIS DATE WILL NOT BE ACCEPTED.
POSTMARKED MEANS DATE STAMPED BY THE POST OFFICE ON THE DAY THAT YOU POST THE APPLICATION
FORM. REGISTERED MAIL IS RECOMMENDED
(Please tick one box only)

Dr
Mr
Given Names

Mrs
Ms
Miss
Family Name......................................................................................................................................................................
...............................................................................................................................................................................................................................
Gender
Male
Date of Birth ___ ___ / ___ ___ / ___ ___ ___ ___
DD
MM
YYYY
Female
Postal Address
.....................................................................................................................................................................................................................................................................................................................................................................
.........................................................................................................................................................................................................................................................
Telephone (
Facsimile (
) ..................................................................................
(AH)
) ................................................................................................
) ........................................................................................ (BH)
Post Code ................................................................
........................................................................................................
(Mobile)
Email Address ..................................................................................................................................................................................................................
Are you currently or have you ever been a JCU Student JCU
Yes
No
(if yes) JCU ID number __________________
QTAC Application number..........................................................................................................................................................................................................................................................................................................................................
Citizenship Status (please tick one box only):

Australian Citizen.
Australian Permanent Resident
New Zealand Citizen
Are you of Aboriginal or Torres Strait Islander origin? Yes

No
1
Faculty
of Medicine, Health &Molecular Sciences, April 2011

CRICOS 00117J
INSTRUCTIONS
x If one of the courses for which you are applying is the Bachelor of Medicine, Bachelor of Surgery then download and read
the pack for Domestic Applicants before completing this application:
http://www.jcu.edu.au/fmhms/forms/index.htm
x Tick the front page to indicate the degree or degrees that you wish to apply for and complete all sections of the application
form.
x Ensure you provide the same name and date of birth details to James Cook University as on your application to QTAC.
x Complete all sections of this form. Information must be completed in your own handwriting. Failure to complete all
appropriate sections may affect your selection.
x Applicants applying for both Veterinary Science and other courses must complete both written components
x Applicants (other than JCU students) must also apply to and comply with the appropriate QTAC application procedures.
QTAC
http://www.qtac.edu.au
x If you are a current student of JCU or have completed at least one Teaching Period (one semester) of study in the last five
years, you DO NOT apply to QTAC but submit this application together with a Course Transfer Application or Subsequent
Degree Form to the Faculty Student Office, Building 39, Demountable Building Medical 1, Townsville Campus or mail
to PO Box 864 Aitkenvale Business Centre, Qld, 4814. You are not required to attach a certified copy of your academic
record.
Course Transfer Application
http://www.jcu.edu.au/student/idc/groups/public/documents/form_download/jcudev_007458.pdf

Subsequent Degree Application

http://www.jcu.edu.au/student/idc/groups/public/documents/form_download/jcudev_007450.pdf
x Securely attach supporting documentation (where applicable). Send only certified copies as originals cannot be returned to
you.
Certified Copy: A photocopy of an original document that has been certified by those listed under "Document
Certification Requirements" on page 14
x Only one copy of your application will be accepted.
x Return Pages 1-13 of Application
x Enclose a SEALED and STAMPED self-addressed envelope for acknowledgment of receipt of your application. Write the name
of the degree/s you are applying for on the back of this envelope. This envelope will be stamped by the Faculty and returned
to you.

If requesting acknowledgment for documents sent from overseas, including New Zealand, please enclose an International
Reply coupon, available from most Post Offices.
x Return application form by 30 September 2011 to the Faculty Student Office, Building 39, Demountable Building
Medical 1, Townsville Campus or mail to PO Box 864 Aitkenvale Business Centre, Qld, 4814 .
x Express Post is not recommended.
x To ensure your application arrives safely and on time we suggest you use Registered Mail.
Faxed copies of the application or any documentation sent separately will not be accepted.
2
Faculty

CRICOS 00117J
Please indicate which best describes your HIGHEST level of education to date.
PLEASE TICK ONLY ONE OF THE FOLLOWING

Currently studying Year 12 or equivalent (studying Year 12 in 2011)
Completed Year 12 or equivalent (prior to 2011).
Please indicate the year you completed year 12 or equivalent:
Completed TAFE qualifications:

Advanced Diploma
Diploma
Certificate IV
Certificate III
Currently studying a tertiary degree:

How many years will you have completed by the end of 2011? years
(Please complete the Table on page 5)
Completed a tertiary degree:

What level of tertiary study have you completed?
Undergraduate
Postgraduate Coursework
Postgraduate Research
Please indicate the year you completed your most recent level of tertiary study:
(Please complete the Table on page 5)
If none of the above apply to you:

(complete the section below and indicate in detail your qualifications)
(a) the institution you are studying at or have studied with;
(b) the level of qualification you have obtained or are studying; and
(c) how many years study you will have completed of this course at the end of this year.

Name of Institution
Qualification or Course
Completed

Yes/No

Year
Completed OR
Current Year
of Enrolment
3
Faculty
of Medicine, Health &Molecular Sciences,April 2011

CRICOS 00117J
PLEASE DETAIL ALL SCHOOLS ATTENDED FROM YEAR 1 TO COMPLETION OF YOUR SECONDARY EDUCATION.
List each year on a seperate line as indicated in the example below.
If you have completed part or all of your schooling overseas please complete as per the example on line 2 below.
This section must be completed as per example. List all primary and secondary schools attended by year.

Year
Grade
eg. 1986
School Name
Suburb
Town/City
State
Post
Qld
4870
OFFICE USE
Code
Trinity Bay Primary
1987 2 Overseas
Edgehill
Cairns
England
If you completed Year 12 or equivalent PRIOR to 2011 and have NOT commenced tertiary studies, what have you been doing?
Attach certified copy of Year 12 Senior Certificate and Tertiary Entrance Statement (TES) or equivalent.
Work
Travel
Exchange program (ie Rotary)
Other (provide a brief outline below)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
4
Faculty of Medicine, Health &Molecular Sciences, April 2011
CRICOS 00117J
PLEASE LIST ANY TERTIARY STUDIES YOU HAVE ATTEMPTED OR COMPLETED.

Undergraduate and Postgraduate Tertiary Studies DO NOT include Bridging Courses
Attach a certified copy of your academic transcript.

Name of Institution
Qualification or Course
Completed

Yes/No

eg. Central Qld University
BSc
Yes
Year
Completed OR
Current Year
of Enrolment
2005
5
Faculty

CRICOS 00117J
PLEASE NOTE THAT YOU MUST COMPLETE THE STATUTORY DECLARATION

SET OUT BELOW AND HAVE IT WITNESSED
DECLARATION:
I declare that to the best of my knowledge the information on this form is correct and complete. I acknowledge that the
withholding of any information relating to the provision of incorrect information may result in the withdrawal of a place that may
be offered, and, that this withdrawal may take place at any stage during the course.
Signature of applicant ......................................................................................................................................................................................................... Date .................................................................................................................................
Taken and declared before me, at ..............................................................................................................................................................................................................................................................................................................................

This ............................................................................................................................................................................................ day of
....................................................................................................................................................................................
2011.
..............................................................................................................................................................................................................................................................................................................................
A Justice of the Peace/Commissioner of Declarations or equivalent

(as listed under Document Certification Requirements on page 16)
PRIVACY STATEMENT
PLEASE NOTE:
Information contained on this form is collected for selection and administrative purposes. Personal information will not be passed
on to any other external bodies without your authorisation unless a valid legal request has been made.
6
Faculty of Medicine, Health &Molecular Sciences,April 2011
CRICOS 00117J
PREDICTION OF ACADEMIC ACHIEVEMENT

(Currently studying Year 12 in a Secondary school ONLY)
BACHELOR OF MEDICINE, BACHELOR OF SURGERY APPLICANTS ONLY.

TO BE SUBMITTED VIA FAX BY SCHOOL PRINCIPAL/ACADEMIC REFEREE
This page is only to be completed for applicants in the final year of secondary school.
Applicants who have already completed Year 12 do NOT need to provide this as their actual OP, or equivalent, will be provided by
QTAC.
For this applicant to be considered the form is required to be FAXED to the School of Medicine (07) 4781 6986 or
+61 7 4781 6986 by 4pm, 28 October 2011.
NB: This prediction will be used to determine whether a student may be invited to an interview before the actual OP/ATAR results are
available. In final decisions about selection the actual OP/ATAR will always be used. Students whose predicted OP/ATAR is below the
threshold but actual OP/ATAR is at or above it, could be eligible to be invited to a late interview.
This student is currently in Year 12 of secondary school. Based on their performance to date, I estimate
that their Year 12 results will be close to:
Queensland
This student's Overall Position is expected to lie at or around:
More than
OP10
OP10 OP9 OP8 OP7 OP6 OP5 OP4 OP3 OP2 OP1
New South Wales, Australian Capital Territory, Victoria, South Australia / Northern Territory, Western Australia or Tasmania
This student's ATAR is expected to lie at or around:
Less than
85 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99
International Baccalaureate
This students International Baccalaureate score (out of 45) is expected to lie at or around
Less than
30 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
New Zealand
This student's NCEA rank is expected to lie at or around (Please circle one);
Less than
<90 90 91 92 93 94 95 96 97 98
99 100
GCE "A"Levels - This student is expected to achieve the following results (Please circle one);
AAA
AAB
ABB
AAAA
AAAB
AABB
ABBB
Other: __________________________
Any other final secondary school examination

Based on past academic performance, in a year cohort of ________ students, this student is expected to lie in or around:
Less than
Top 25%
Top 25%
Top 20%
Top 15%
Top 10%
Top 5 %
Top 2 %
of their cohort
General Comments on the Applicant: (if applicable)

Place school stamp or seal in the
box above
Student's Family Name:...............................................................................................................................................................................................................................................................................................................................................................
Given Names:...............................................................................................................................................................................................................................................................................................................................................................................................
(Names must be the same as on QTAC application.)
Gender
Male
Female
Date of Birth
_ _/_ _/_ _ _ _
DD MM YYYY
School Name: .............................................................................................................................................................................................................................................................................................................................................................................................

Address of School: ..............................................................................................................................................................................................................................................................................................................................................................................
Name of Principal/Academic Referee: ...............................................................................................................................................................................................................................................................................................................
Position: .................................................................................................................. Telephone:....................................................................................................... Facsimile:...............................................................................................................
Signature: ..........................................................................................................................................................................................................................................................................................................................................................................................................
7
Faculty

JCU University CRICOS Provider Codes: QLD: 00117J NSW: 1965E VIC: 02153M
8
CRICOS 00117J
Office Use Only
DATA No
2 0 1 2
E N T R Y
BACHELOR OF DENTAL SURGERY

BACHELOR OF MEDICINE BACHELOR OF SURGERY
BACHELOR OF PHARMACY
BACHELOR OF PHYSIOTHERAPY
W R I T T E N
C O M P O N E N T
PLEASE COMPLETE THE FOLLOWING IN YOUR OWN HANDWRITING

Dr
Given Names

Mr
Mrs
Ms
Miss
Family Name......................................................................................................................................................................
...............................................................................................................................................................................................................................
Gender
Date of Birth ___ ___ / ___ ___ / ___ ___ ___ ___
DD
MM
YY
Male Female
9
Faculty

CRICOS 00117J
Please complete the remaining sections of this form in your own handwriting in black or blue ink.
Either cursive or print is acceptable (computer generated responses will not be accepted).
PLEASE ANSWER THE FOLLOWING QUESTION WITHIN THE LINE SPACE PROVIDED.
1. Why do you want to become a medical practitioner / health professional?
2. T ell us why you are interested in enrolling in a course where important themes are rural, remote, Indigenous and tropical
health and medicine?
10
CRICOS 00117J
3. W
hat activities (paid employment, work experience or voluntary) have you undertaken, in addition to your studies, which
indicate your motivation to study medicine or another health professional degree at James Cook University?
4. Provide any other information you believe is relevant to your application.
11

Faculty
CRICOS 00117J
PLEASE ATTACH LETTERS OF SUPPORT HERE

You may attach up to three letters of support to your application (this is not compulsory). If you choose to attach letters of
support, make sure to ask your referees to include their phone number in case we need to contact them. You must keep a copy
of any letters of support (and your completed application) as no documentation can be returned to you.
Only the first three (3) letters of support will be read.
Do not send letters of support separately as they will not be included as part of your application.
Letters of support from family members will not be accepted.
LETTERS
OF
SUPPORT
12
CRICOS 00117J
Office Use Only
DATA No
2 0 1 2
E N T R Y
BACHELOR OF VETERINARY SCIENCE
W R I T T E N
C O M P O N E N T
PLEASE COMPLETE THE FOLLOWING IN YOUR OWN HANDWRITING

Dr
Given Names

Mr
Mrs
Ms
Miss
Family Name......................................................................................................................................................................
...............................................................................................................................................................................................................................
Gender
Date of Birth ___ ___ / ___ ___ / ___ ___ ___ ___
DD
MM
YY
Male Female
13

Faculty
CRICOS 00117J
Please complete the form neatly in your own handwriting in black or blue ink.
Either cursive or print is acceptable (computer generated responses will not be accepted).
1. Why do you wish to pursue a career in Veterinary Science?
2. W
hat activities (paid employment, work experience or voluntary) have you undertaken, in addition to your studies, which
indicate your motivation to study Veterinary Science?
14
Faculty

CRICOS 00117J
3. T ell us why you are interested in enrolling in a veterinary science course which has a strong focus on rural, regional and
tropical practice.
4. Is there any other information you believe is relevant to your application?
15
CRICOS 00117J
PLEASE ATTACH LETTERS OF SUPPORT HERE

You may attach up to three letters of support to your application (this is not compulsory). If you choose to attach letters of
support, make sure to ask your referees to include their phone number in case we need to contact them. You must keep a copy
of any letters of support (and your completed application) as no documentation can be returned to you.
Only the first three (3) letters of support will be read.
Do not send letters of support separately as they will not be included as part of your application.
Letters of support from family members will not be accepted.
LETTERS
OF
SUPPORT
16
CRICOS 00117J
DO NOT RETURN THIS PAGE

APPLICATION CHECKLIST
2012 ENTRY
HAVE YOU:
Applied to QTAC and/or JCU by the closing date of 30 September 2011?
Detach and keep for your records
Completed all sections of the application form (where applicable)?

Written your JCU student number on the application form (if applicable)?
Used the same name and date of birth on the JCU application as was provided to QTAC (if applicable)?
Completed your application form and the appropriate written component neatly, in your own hand writing
using black or blue ink in either cursive or print (computer generated responses will not be accepted)?
Attached certified copies of your final school results and/or tertiary academic transcript (as applicable)?
Attached a Course Transfer Application or Subsequent Degree Form (JCU students only)?
Read and signed the Declaration in the presence of the person witnessing your application?
Enclosed a SEALED and STAMPED self-addressed envelope for acknowledgment of receipt of your
application? Write the name of the degree/s you are applying for on the back of this envelope (This
envelope will be stamped by the Faculty and returned to you).
If requesting acknowledgment for documents sent from overseas (including New Zealand), please enclose
an International Reply coupon, available from most Post Offices.
Kept a photocopy of this application for your records?
DOCUMENT CERTIFICATION REQUIREMENTS

When preparing your application to James Cook University, it is essential that you supply correct and complete supporting
documentation. Failure to do so may affect your selection.
You must submit certified copies of documentation (where requested) with your application. Uncertified copies, and
photocopies of certified copies are not permissible.
James Cook University will accept copies certified by:
x A James Cook University (JCU) registered agent
x A Justice of the Peace (JP)
Detach and keep for your records
x A Commissioner of Declarations
x A Barrister, Solicitor, Pharmacist, Medical Practitioner
x The University Admission Centre of any Australian state e.g. QTAC, VTAC, UAC
x An Australian overseas diplomatic mission
x A Police Officer at, or above the rank of Sergeant
x Current School Principal
The person certifying photocopies of original documentation must state "I certify this to be a true copy of the original which I
have sighted at the time of signing", provide their signature, occupation and telephone number and affix the official stamp or
seal of their organisation, if available, on the front of each copy.
Please note that it is your responsibility to ensure that your application is complete at the time of submission.
Qualifications/other documentation written in a language other than English:

Please provide certified translations and a certified copy of the original documentation.
17
CRICOS 00117J
18
CRICOS 00117J

Jcudev 013758

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Office Use Only

JAMES COOK UNIVERSITY

Bachelor of Dental Surgery

(Please tick one box only)

Post Code ................................................................

Email Address ..................................................................................................................................................................................................................

(if yes) JCU ID number __________________

Citizenship Status (please tick one box only):

Australian Permanent Resident

New Zealand Citizen

Are you of Aboriginal or Torres Strait Islander origin? Yes

Subsequent Degree Application

PLEASE TICK ONLY ONE OF THE FOLLOWING

Completed TAFE qualifications:

Currently studying a tertiary degree:

Completed a tertiary degree:

If none of the above apply to you:

Trinity Bay Primary

Exchange program (ie Rotary)

Other (provide a brief outline below)

PLEASE LIST ANY TERTIARY STUDIES YOU HAVE ATTEMPTED OR COMPLETED.

PLEASE NOTE THAT YOU MUST COMPLETE THE STATUTORY DECLARATION

A Justice of the Peace/Commissioner of Declarations or equivalent

PREDICTION OF ACADEMIC ACHIEVEMENT

BACHELOR OF MEDICINE, BACHELOR OF SURGERY APPLICANTS ONLY.

Any other final secondary school examination

General Comments on the Applicant: (if applicable)

Office Use Only

JAMES COOK UNIVERSITY

BACHELOR OF DENTAL SURGERY

PLEASE COMPLETE THE FOLLOWING IN YOUR OWN HANDWRITING

(Please tick one box only)

PLEASE ATTACH LETTERS OF SUPPORT HERE

Office Use Only

JAMES COOK UNIVERSITY

PLEASE COMPLETE THE FOLLOWING IN YOUR OWN HANDWRITING

(Please tick one box only)

PLEASE ATTACH LETTERS OF SUPPORT HERE

DO NOT RETURN THIS PAGE

Detach and keep for your records

Completed all sections of the application form (where applicable)?

DOCUMENT CERTIFICATION REQUIREMENTS

Qualifications/other documentation written in a language other than English:

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