Case Officer: _____________________ Mobile No. ___________________
STUDENT REGISTRATION FORM Part A: Personal Details: Family/Name_______________________________ Other Names___________________________________________________ Date of birth ____________________ M/F _______ ID No. ___________________ Tel/Mobile: ___________________________ E-mail: _____________________________________________________Passport No.__________________________________ Marital Status: (Please tick as applicable) Married How did you hear about us? Event
Single
Other (specify): _______________________________
Referral by Friend/Relative
Postal Address
Advertising
Other
Physical Home Address
Next of kin __________________________________________________Tel/Mobile: ____________________________________ Relationship____________________Address___________________________________________________________________ (E.g. mum/dad/uncle) (Write “as above” if same as yours) PART B: Education Background: Please indicate your education certificates below Certificate
Grade
Period (E.g. 2006 – 2009)
School/college/university
Submitted
Work Experience: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ IELTS Overall band score: ________________ PTE Score: ______________________
TOEFL Score: ________________
Preferred courses: 1st Choice __________________________________________ 2nd Choice: _________________________________________ I have given Options Education Agency authority to forward my application for enrolment to a Diploma and/or University course in Australia. I declare that the information provided in this form is true and correct to the best of my knowledge. Signed: ……………………………………… (By parent/guardian if student is under 18 Yrs. old). Date: …………………………………
Australia: P O Box 149, Rundle Mall, Adelaide 5000. Level 7 Suite 76, 118 King William Street, Adelaide 5000. Telephone: +61 8 8231 4000 Mobile: +61 422 767 666, Visit our website www.optionseducation.com.au E-Mail: student@optionseducation.com.au Africa: 2th Floor, The Mall, Westlands, Nairobi, Kenya. Tel +254 20 8045494 Mbl: +254 0703 462 988 / 0735 841 044