CSU GLOBAL EXCHANGE PROGRAM
APPLICATION FORM - OUTGOING CSU
STUDENTS
Charles Sturt University (CSU) is a registered provider under the Commonwealth
Register of Institutions and Course for overseas students.
The Commonwealth Register of Institutions and Courses for Overseas Students
(CRICOS) Provider Numbers are 00005F (NSW) and 01947G (VIC) for Charles Sturt
University.
This application form is for preliminary acceptance into the CSU Global Exchange Program and does
not guarantee acceptance into a host institution. If you are accepted into the CSU Global Exchange
Program, CSU Global will advise what further documentation you are required to submit to apply for
a place at a host institution.
CLOSING DATES
Session 1 (January – May) – July 1
Session 2 (August – December) – December 1
PRIVACY STATEMENT
The personal information you provide in this form is governed by the Privacy and Personal Information
Protection Act 1998, the Health Records and Information Privacy Act 2002 and CSU’s Privacy Management
Plan (the Privacy Legislation). Your information will be collected by CSU Global to assess whether you are a
suitable student to send overseas to a host institution and to assess you for any travel or scholarship grants.
If you are accepted into the CSU Global Exchange Program, your information may be disclosed to
authorised personnel at a host institution to assess your eligibility to secure a place at that host institution.
Your personal information will not otherwise be made available to any other person or organisation for any
other purpose without your consent except where CSU may be legally required to do so. The provision of
personal information in this form by you is voluntary but if this information is not provided, CSU Global may
not be able to assess your application in a timely manner.
You have a right of access to, and correction of, your personal and health information in accordance with the
Privacy Legislation. Please direct any enquiries you may have in relation to this matter to CSU Global. If
you are unhappy with the way CSU has handled or failed to handle your personal information, you may apply
to have the matter reviewed by lodging a complaint with the CSU Ombudsman.
CONTACT DETAILS
Title:
Family Name:
Given Names:
Other
Country of Birth:
Date of Birth:
Are you an International Student:
dd/mm/yy
Nationality:
Address for correspondence:
Postcode:
Student number: Preferred contact phone no:
CSU Global Exchange Program
Sex:
male
female
Permanent address (if different to correspondence
address)
Postcode:
Email address:
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CURRENT ENROLMENT DETAILS
Course:
Faculty:
Year:
Year Commenced Course:
yyyy
•
Please attach a copy of your transcript showing current enrolment details and previous results
FUNDING INFORMATION
Would you like to be considered for:
Vice-Chancellor Travel Grant
Endeavour Student Exchange Program S’ship
OS HELP Loan
Yes □
Yes □
Yes □
No □
No □
No □
ADDITIONAL PERSONAL INFORMATION
Do you have a disability or ongoing medical condition, which will require you to seek special assistance from
the host institution? i.e. hearing/visual impairment, mobility/learning/medical requirements
Yes
No
If yes, please provide details.
EMERGENCY CONTACT
I appoint the following person as my designated Emergency Contact and authorise CSU and/or the host
nstitution to contact the person for, or with, information about me if a need arises. I have fully informed my
Emergency Contact regarding all aspects of my prospective exchange, including the nature of possible risks.
This emergency contact arrangement is valid from the date of my signature on this application until
completion of the exchange program I am accepted into.
Title:
First Name:
Middle name/s:
Last Name
Primary Contact Number: :
Email:
Secondary Contact Number:
Home address:
DESTINATION UNIVERSITY
First Preference:
Second Preference:
Semester you would like to study on Exchange: Number of sessions:
Session 1:
Session 2:
1 session:
2 sessions:
Year: __
CSU Global Exchange Program
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STATEMENT OF PURPOSE (1000 WORDS – in total) – Please attach as a separate page
•
Explain why you wish to take part in Exchange Program and what you hope to achieve academically
and personally.
•
Why did you choose the particular country and university?
•
Describe ways you will be an effective ambassador for CSU while on Exchange.
•
List any non-academic achievements and participation in other activities that support your
application.
COURSE DIRECTOR APPROVAL
Your Course Director must sign this section of your application form.
I support the application of this student to undertake one or two sessions of study overseas through the CSU
Global Exchange Program.
Course Director Name: ....................................................................................
Date: ..........................................................
dd/mm/yy
Signature: ....................................................................................
SOURCES OF FINANCIAL SUPPORT AND ESTIMATED COSTS
The following table is designed to assist you in researching the costs associated with studying on Exchange.
A normal semester on Exchange will cost between AUD$10, 000 – AUD$15,000. Students applying to
study in the United States of America, United Kingdom and Japan will be required to submit
documentation to confirm their financial capabilities in order to obtain a student visa. Students
applying to these locations will need to provide this information before final confirmation of
exchange placement.
Available Funds
Estimated Costs
Savings to date
$_____________
Airfare
$____________
Expected savings now to
departure
$_____________
Travel/Medical Insurance
$____________
Visa/Passport
$____________
Parents or other Sponsors
(Please attach a letter of
support)
$_____________
Accommodation
$____________
Textbooks/stationary etc
$____________
Centrelink (You should seek
advice from Centrelink on
continuing this payment
throughout an exchange)
$ ____________
Meals
$____________
Daily living allowance
$____________
Other
$ ___________
Total Estimated Costs
$ ___________
$ ____________
$ ____________
Scholarships – Please
Specify
$ ____________
OS HELP Loan
$ ____________
Other – Please Specify
$
Total Available
$
CSU Global Exchange Program
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STUDENT ACKNOWLEDGEMENT, DECLARATION AND AGREEMENT
By inserting a  against each of the following statements and signing where indicated, you confirm your understanding and acceptance
of the acknowledgements, declarations and agreements set out below and that CSU may rely on and enforce these acknowledgements,
declarations and agreements.
My Application
I declare that all the information submitted on this application is correct and complete.
I understand that the provision of false or misleading information may result in non-acceptance of this application or immediate
expulsion from the CSU Global Exchange Program.
I understand that my application is for preliminary acceptance into the CSU Global Exchange Program and does not guarantee
acceptance into a host institution.
I understand that the decision of CSU Global is final with respect to the preliminary acceptance into the CSU Global Exchange
Program.
I agree to advise CSU Global if there are any changes to the information I have given in this application.
My privacy
I acknowledge that I have read the Privacy Statement on the first page.
I consent to the collection of my personal information contained in this application by CSU Global and, subject to my acceptance
into CSU’s Global Exchange Program, to the disclosure of such information to a host institution for the purpose of assessing my
eligibility for a place at that university.
I consent to CSU Global disclosing my personal information to the host institution, my designated Emergency Contact and any
Australian or foreign government agencies, for any purpose related to the protection of my safety and welfare.
My safety
I acknowledge that CSU does not warrant that the host country is a safe and suitable country for overseas travel and that my
decision to travel to a particular country or region is a personal one.
I acknowledge that I am required to register my travel online at http://www.smartraveller.gov.au/ and Travel Tracker to keep myself
updated with the latest travel advice from this website.
I acknowledge that I am required to undertake the CSU Global Pre-Departure modules and agree to follow any relevant directive
issued by the Australian Embassy or High Commission or other Australian Government representative in the host country
I understand that CSU can require my withdrawal from the exchange program should it deem political instability and/or terrorist
activities in the region to be unsafe for me to remain in my host country.
My participation in CSU Global Exchange Program
I agree to advise CSU Global of any changes in the arrangements of my exchange program.
I agree to advise CSU Global if my GPA falls below 4.5 before leaving to go on exchange.
I understand that a lower GPA could result in my removal from CSU Global Exchange Program at any point prior to departure.
I understand and accept that I must comply with the academic rules and regulations in place at the host institution and the laws
applicable in the host country at all times and that any failure to do so may result in my exclusion from the host institution or expulsion
from the host country at my own cost.
I understand that I am bound by, and must comply with, the CSU Academic and Student General Misconduct Rule at all times
during my exchange.
I will not participate in any activity, including political activity, which might endanger either CSU or the host institution, or undermine
the effectiveness or viability of the exchange program.
I understand that CSU Global can require my withdrawal from the exchange program for conduct unbecoming of a student of CSU,
and will be sole authority in exercising this judgement.
I am responsible for applying for and obtaining any relevant visa associated with my exchange and travel.
I understand that it is my responsibility to negotiate and obtain approval from CSU for obtaining academic credit for study
completed at the host institution.
My financial obligations
I understand that my participation in this exchange program and associated travel is my sole responsibility and I assume all
financial responsibility, including debt, arising from such circumstance.
I am aware of the likely living cost of my stay overseas, and I have the necessary financial capacity to meet such costs for the full
duration of my exchange period.
I understand that I am responsible for the costs of travel, insurance, living and any additional host university expenses.
I understand that I am liable for CSU subject tuition fees and other CSU costs while I am on exchange.
I have obtained and will maintain for the duration of my enrolment with CSU adequate health and travel insurance coverage.
CSU Global Exchange Program
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I agree that I am responsible to ensure that my travel and medical insurance covers me for the total period of my travel including
any independent travel before, after and during the exchange program.
My liabilities
I agree to indemnify CSU for any expenses, losses, damages and costs that I may sustain or incur as a result, whether directly or
indirectly, of any action arising from any failure by myself to obtain or maintain travel and medical insurance coverage. I understand that
compulsory health insurance may be mandatory at my host institution. This may be in addition to the coverage I have purchased prior
to departure.
I agree that CSU and its staff are not to be held accountable for any injury or loss I may suffer when I am acting or travelling
independently before, after and during the program.
I understand that CSU will not be liable in any way for injury, sickness or damage that I may suffer during my participation in the
exchange program and/or resulting from the travel arrangements and any other related or incidental activities during this program.
General
I have sought and obtained appropriate advice on my responsibilities as set out in this Acknowledgement, Declaration and
Agreement.
I understand that my testimonials/quotes and or video footage/photographic images taken of me while on this interntational
program are for free and unrestricted use by Charles Sturt University and its agents in editorial, advertising, educational and
promotional material.
I understand that tKHLQWHUQDWLRQDOFRS\ULJKWDQGLQWHOOHFWXDOSURSHUW\ULJKWVRQWKHVHPDWHULDOVZLOOUHPDLQWKHSURSHUW\
RI&KDUOHV6WXUW 8QLYHUVLW\ZKRZLOOEHHQWLWOHGWREURDGFDVWSXEOLVKRURWKHUZLVHGLVWULEXWHWKHVHPDWHULDOVDQGDQ\SURGXFWWKHUHRI LQ
DQ\ZD\RUPDQQHUWKDWWKH\ VHHILWLQSHUSHWXLW\0\VLJQDWXUHEHORZsignifies my approval, and I therefore have no further claims for
compensation from Charles Sturt University or its agents.
□
I consent to the distribution of my personal and contact details to CSU divisions, external organizations and Government
departments in relation to this program. Please note if you are a participant in a government funded program part of the funding
agreement is that your personal details will be released to this body.
I understand that this Acknowledgement, Declaration and Agreement cannot be modified or amended except in writing by CSU.
Signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Checklist
□
Completed application form
□
Academic Transcript
□
A 1000 word Statement of Purpose
□
Asked 2 academic staff to forward Academic Referee Report to CSU Global
Date. . . . . . . . . .
dd/mm/yy
Please note: Your application will not be assessed until you have submitted all the information listed above.
If you are unable to provide all of the information above please note why and when you will be able to submit
it.
Once your application and supporting documents have been received you will be notified by CSU Global as
to your success in receiving an offer for the CSU Global Exchange Program. You will then be asked to
complete additional documentation to secure your place at your nominated exchange destination. Students
may also be required to attend an interview as part of this process.
CSU Global Exchange Program
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