Faculty of Health Sciences
CRICOS Provider Number 00123M
Application for Honours
AUSTRALIAN RESIDENTS AND NEW ZEALAND CITIZENS ONLY
Bachelor of Health Sciences (Honours)
Honours Degree of Bachelor of Medical Science (for MBBS students only)
Bachelor of Nursing (Honours)
Section A: PERSONAL INFORMATION
Title: Dr/Mr/Ms/Mrs/Miss (Please circle)
Telephone (home) Telephone (work)
Facsimile email address
Date of Birth: Gender: Male Female
Citizenship: Australian citizen
New Zealand citizen
Holder of permanent visa
Holder of a permanent humanitarian visa
University of Adelaide Student Number ______ (if previously enrolled)
Do you wish to study Full-time Part-time
Commencement: Semester 1 Semester 2 Expected completion
The completed form should be sent to the
Faculty of Health Sciences, The University of Adelaide, North Terrace, Adelaide SA 5005
Section B: UNDERGRADUATE QUALIFICATIONS
Please give details of your undergraduate qualifications.
Qualification obtained Institution/University Year of Study
Section C: POSTGRADUATE STUDIES
Please give details of all your postgraduate studies (whether completed or not completed) .
Qualification Level of Honours Institution/University Year of Study
obtained obtained From To
Section D: APPROVAL FROM SCHOOL
I, _______________________________ confirm that this student has been accepted by the
_________________________________ to study Honours. I further confirm that I have viewed
the academic transcript for this student and have found the student to be academically suitable
for this position.
The student’s supervisor will be ________________________________________________
Start date is: ____________________ Expected finish date is: ________________________
Campus/location of study _________________________________________________
Honours Coordinator signature: ____________________________ Date: ____/_____/_____
Student signature: _______________________________________ Date: ____/_____/_____
Section E: DECLARATION AND AUTHORISATION
I declare that the information supplied by me on this form is complete, true and correct in every particular.
I authorise the University to obtain from other educational institutions and relevant authorities at any time, details of my enrolment,
academic record, examination results and bond status, including details of enrolment variations, attendance and addresses during
the year in connection with my application.
I authorise the release of this application and supporting documents to appropriate persons within Adelaide University in confidence
as part of any selection process for admission, which might follow.
I agree to abide by the University’s conditions of award and course regulations and rules, where applicable.
I understand that the University of Adelaide is collecting the information in this form for the purposes of assessing my entitlement to
Commonwealth assistance under the Higher Education Support Act 2003 and allocation of a Commonwealth Higher Education
Student Support Number (CHESSN) to me; the University of Adelaide will disclose this information to the Department of Education,
Science and Training (DEST) for those purposes; DEST will store the information securely in the Higher Education Information
Management System; DEST may disclose the information to the Australian Taxation Office (ATO); and the University of Adelaide
and DEST will not otherwise disclose the information without my consent unless required or authorised by law.
I consent to the disclosure of information where appropriate by the University to the Australian Vice-Chancellors Committee or any
AVCC member institution.
Signature ________________________________________________ Date ______/______/_______