Exchange Application
Outbound Students


This form is for students who wish to apply to participate in the Otago Polytechnic Student
Exchange & Study Abroad Programme.
Please ensure that you complete all sections of the form and sign the declaration. .
Application Deadlines
Application deadlines are set year-by-year, and according to the time of the exchange. Please
contact the Study Abroad & Exchange office for more information: [email protected]
Who can apply?
Students must meet the following criteria to be eligible to apply to participate in an exchange
programme:
 Be enrolled in a full-time degree programme at Otago Polytechnic;
 Have completed their first year of study before departure;
 Have a B grade average or equivalent (some of our partner institutions may require a
higher average, and some programmes are flexible regarding a lower average).
Additional Information required
In addition to the completed application form, you should include the following documentation:
 A one-page Letter of Motivation that explains the reason for the application. This
statement can focus on how the exchange could benefit your studies and career
goals
 Your CV
 Letter of recommendation (from your Programme Manager)
 An exchange referee form; find attached to this application form (from a lecturer)
 Transcript of records with grades and credit information (you can obtain this from
Customer Services)
 Scanned copy of your passport
 A passport size photograph (jpg or jpeg, file size: 3x4 cm, min. 200 pixels, max. 50
kb size)
Note: Your Letter of Motivation can include your personal reasons for choosing to study overseas and
how it will enhance your future career and study options. Make sure to include any information you
think maybe relevant to living and studying overseas such as previous travel, hosting of an international
student, membership of professional organizations and so on. You may also include non-academic
reference letters to support your application and your resume.
Application Process
Stage 1: Once you have submitted your application to the Exchange Office, and the
application deadline has been reached, a panel of Otago Polytechnic staff will assess all
applications. If your application is deemed suitable you will be invited to an interview shortly
afterwards. You will be informed within a week whether you will be proceeding to Stage 2.
Stage 2: This stage involves submissions to your preferred institutions. A member of staff
will assist you in filling in the application forms by the due date for the institution you have
chosen.
Outbound Exchange Application Form - rev Feb 2017
Exchange Application
Outbound Students
Personal Information
Name:
(Surname)
_______
(Middle)
(First)
Date of Birth:
Student ID no:
_______
Please tick the appropriate box:
New Zealand or
Australian citizen
New Zealand
Permanent Resident
International
Student
Nationality on Passport: _________________________ Passport Number:_____________
Contact Address:
________
__
Phone Number:
Email:
Please list your interests and activities (including any academic honours):
________
________
_________________________________________________________________________
(Use a separate sheet of paper if necessary)
If you have travelled or studied abroad, list the countries visited, the duration, and purpose
of your stay (i.e. holiday, sporting trip, study):
Country
Duration of stay
Purpose
________
________
(Use a separate sheet if necessary)
Outbound Exchange Application Form - rev Feb 2017
Please summarise your work experience (include holiday work):
Job
Employer
Period
______
(Use a separate sheet if necessary or include your Resume/Curriculum Vitae)
Academic Information
Current Degree:
_________________________
Major/Specialisation:
_________________________
Have you attended another tertiary institution? Please give details:
Exchange Information
Please list the exchange programmes/partner institutions you wish to apply for (in order of
preference):
1.
2.
3.
Please note that the Exchange Programmes are based on reciprocity between Otago
Polytechnic and our partner institutions (equal exchange of students between institutions
over a two-year period). For this reason we ask for three preferences to ensure a balance of
incoming and outgoing students.
Proposed commencement date for exchange:
Length of exchange:
One Semester
One Year
Short Course
Please identify any health limitations or serious illness that may affect or limit your study
abroad experience (e.g. diabetes, epilepsy):
Have you been deported from another country, or have you had any criminal convictions
that may have an impact on your application for a Student Visa?
Yes
No
If yes, please give details:
Please advise of any dietary requirements or special needs that you have that your host
institution should be aware of:
(Use a separate sheet if necessary)
Outbound Exchange Application Form - rev Feb 2017
Financial Information
Please indicate how you intend to finance your living costs during your time abroad:
Personal Savings
$
Parental Support
$
Loans & Allowances $
Grant (if applicable)
$
Other*
$
TOTAL
$
*If your income is from ‘other’, or if you intend to apply for a financial assistance grant, (e.g.
Rotary, Iwi) please specify.
REMEMBER THAT YOU WILL NEED TO PROVIDE EVIDENCE OF YOUR
FINANCIAL ABILITY TO SUPPORT YOURSELF WHILE STUDYING OVERSEAS
TO OBTAIN A STUDENT VISA. (A Student Visa is an official document in your
passport that allows you to study in a foreign country.)
Declaration
I declare that the information set out in this application and on the attachments is true and
correct.
I declare that I have not withheld any information that could have a bearing on my application.
I understand that the Privacy Act 1993, allows Otago Polytechnic to hold and use information
about me in accordance with the Act. I authorise Otago Polytechnic to collect, use and
disclose personal information provided by me, relevant to my application.
I understand that my application is subject to the guidelines of Otago Polytechnic Exchange
Programme and that the final decision on my application rests with the host institution.
Applicant’s signature:
____________________________
Print Name: ____________________________________________________________
Date:
I give my permission for Otago Polytechnic to use my name, details and in promotion of this
Exchange Programme.
I agree to provide a presentation about my experience upon my return.
Applicant’s signature:
Date:
_______
Outbound Exchange Application Form - rev Feb 2017
Exchange Application
Outbound Students
Exchange Referee Form
This student has applied to participate in an Otago Polytechnic exchange programme. The
applicant is required to provide a referees’ report with their application. You may give this to
the applicant to submit with his/her application. Your time in writing this report is
appreciated.
Applicant’s name
Surname)
(First)
(Middle)
Student ID no:
Current Degree:
______
Majors:
Host Institution applied for:
Referee’s name:
____________________________________
Position or Relation to Applicant:
______________________________
Academic Attributes
Competence in qualification
Academic interest and motivation
Capacity for independent study
Adjustment to teaching styles
Unknown
Level of maturity
Adaptability to different circumstances
Self confidence and self esteem
Resourcefulness
Reliability
Integrity
Unknown
Excellent
Excellent
Good
Fair
Poor
Comments
Good
Fair
Poor
Comments
If you would like to make any further comments please write them on the reverse side or in
a separate letter.
Referee’s signature:
Date:
Outbound Exchange Application Form - rev Feb 2017