OFFICE USE ONLY
Received by:
_________________
Signature: ___________________
Payment received? ___________
Date: ____ / ____ / __
ENROLMENT FORM
SMS:________________
____
Instructions:
Fill in all sections clearly and carefully by writing in block letters.
Information requested on this form is for national database and tracking purposes and assists in ongoing qualification issuance as
required.
All data is confidential and is not forwarded to any other party with the sole exception of the national statistical database to inform future
federal funding in Vocational Training.
1 PERSONAL DETAILS
Title: (Please tick)
Mr
Mrs
Miss
Ms
Dr
Other
Family Name:
______________________________________________________________________________________
Given Names:
______________________________________________________________________________________
Residential Address:
___________________________________________________________ Post Code:
______________
Postal Address:
___________________________________________________________ Post Code:
______________
Phone Numbers:
Email:
Date of Birth
Home _______________________ Work ________________________ Mobile ________________________
_____________________________________________________________________________________________
___________________________________
Gender:
_______________________________
Emergency/Next of Kin Contact Details: Name ___________________________________________ Phone: ____________________
2 COURSE DETAILS
Name of course/qualification currently undertaking: __________________________________________________________________
Date of enrolment: ____________________________________________________________________________________________
Training Agreement No. (Applicable to Traineeships Only) _____________________________________________________________
3 EMPLOYMENT DETAILS
Business Name: ______________________________________________________________________________________________
Contact Name: _______________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
Town/Suburb ____________________________________________________ Telephone: _________________________________
4 LANGUAGE AND CULTURAL DIVERSITY
Are you of aboriginal or Torres Strait Islander origin?
(For persons of both Aboriginal AND Torres Strait Islander origin,
mark both “Yes” boxes)
No
Yes, Aboriginal
Yes, Torres Strait Islander
Were you born in Australia?
_________________________ If not, please specify? _______________________________________
Do you speak a language other than English at home?
No, English only (Go to disability section)
Yes, other – please specify
How well do you speak English?
Very Well
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Well
Not well
Not at all
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5 DISABILITY
Do you consider that you have a disability, impairment or long-term condition? (You may indicate more that one area)
No
Vision
Hearing/Deaf
Physical
Medical Condition
Other
Intellectual
Mental Illness
Learning
Acquired Brain Impairment
6 EDUCATION
What is your highest completed school level?
In which year did you complete that school level
Completed year 12
Completed year 11
Completed year 10
Completed year 9 or equivalent
Completed year 8 or lower
Did not go to school
Are you still attending secondary school?
Yes
No
Have you successfully completed any of the following qualifications?
Yes (please tick ANY applicable boxes)
No ( Go to the Employment section)
Bachelor Degree or Higher Degree
Certificate III (or Trade Certificate)
Advanced Diploma or Associate Degree
Certificate II
Diploma (or Associate Diploma)
Certificate I
Certificate IV (or Advanced Certificate/Technician)
Certificates other than the above
7 EMPLOYMENT
Of the following categories, which best describes your current employment status? (Tick ONE box only)
Full-time employee
Employed – unpaid worker in a family business
Part-time employee
Unemployed – seeking full-time work
Self employed – not employing others
Unemployed – seeking part-time work
Employer
Not employed – not seeking employment
8 STUDY REASON
Of the following categories, which best describes your main reason for undertaking this
course/traineeship /apprenticeship? (Tick ONE box only)
To get a job
To develop my existing business
To start my own business
To try for a different career
To get a better job or promotion
It was a requirement of my job
I wanted extra skills for my job
To get into another course of study
For personal interest or self development
Other reasons
PAYMENT
TYPE(tick):
 CASH
 CHEQUE
 CREDIT
CARD
 ACCOUNT
Amount to Pay:
Deposit:
Balance Due:
Purchase Order:
Account Sent To:
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CREDIT CARD PAYMENT
TYPE(tick):
 VISA
 MASTERCARD
 BANKCARD
Name on Card
Number on Card
____ /____/____/____
Exp: _ _ / _ _
Please debit the amount of:
Signature
DECLARATION
I declare that the information provided by me is true and correct.
I further confirm that I have read, understood and agree and accept the Terms and Conditions of Enrolment and agree to be bound by them
and will comply with all policies and procedures as detailed in the student handbook. I do hereby certify that this application has been
completed by me personally.
The terms and conditions of this enrolment application do not remove the right of the student to undertake action under Australia’s
consumer protection laws.
NQ Powertrain Pty Ltd will not provide or disclose to any outside parties personal information other than is approved in this application.
However, if required by law then this information will be released.
I further consent to being contacted by NQ Powertrain Pty Ltd and/or the relevant Commonwealth and State agency in connection with my
enrolment and future studies.
Student Name: ______________________________________
Student Signature: ___________________________________
Date: _____ / ______ / ___________
Acknowledgement and Consent
I further acknowledge and provide unconditional consent to my testimonial and/or photograph and/or video to be used in
NQ Powertrain Pty Ltd newspaper, poster, television, flyer and/or any other marketing whilst I am a current or former
student.
Please tick:
YES NO 
Student Signature: ___________________________________
BANK DETAILS
NQ Powertrain Pty Ltd Bank details
are:
Bank: Bendigo Bank
Branch Number: 633 000
Bank Account Number: 140440546
Account Name: NQ Powertrain Pty Ltd
Fee and Cancellation Policy:
25% Deposit is required to confirm enrolment
Balance of fees payable on or before commencement of programme
Deposit is non refundable
Full attendance is required to achieve successful completion of any programme
NQ Powertrain looks forward to helping you achieve your goals
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