Master of Minimally Invasive Surgery

Applicant Details

Home Address

Postal Address

Contact Phone Numbers

Status

Qualifications

Applicants should:

• have completed, or be within 1 year of completing, the FRACS (or equivalent).
• have a Fellowship training position or a post-Fellowship or consultant position in a surgery subspecialty or gynaecology in Adelaide, or be able to attend weekly tutorials in Adelaide.

Complete certified transcripts of degrees and diplomas must be attached, unless your qualifications are from the University of Adelaide.

Photocopies must be officially certified as true copies of the original documents.

Documents in a language other than English must be officially certified as true copies of the original documents and must be accompanied by a certified copy of the English translation.

If qualifications were awarded in a different name, please provide evidence of name change.

Academic *

Professional *

Non-award Study * (formal non post-secondary enrolments not completed as part of a degree program)

Employment

Referees

Please attach two letters of reference with full contact details that comment on your academic and/or professional background.

Declaration *

I certify that to the best of my knowledge all documentation and information submitted or made available by me in connection with this application is true, accurate and complete. I acknowledge that the provision of inaccurate or incomplete information may result in the withdrawal of any offer of enrolment or the cancellation of any enrolment allowed on the basis of acceptance of that offer. I consent to the collection, storage and disclosure of information relating to record falsification or other irregular acts in accordance with Universities Australia procedures. I authorise The University of Adelaide to obtain my academic record from other educational institutions. If sponsored I authorise The University of Adelaide to release details of my academic progress to my sponsoring body upon request.

I understand:

1. That The University of Adelaide is collecting information on this form for the purposes of assessing my eligibility for admission to the Program and allocation of a Commonwealth Higher Education Student Support Number (CHESSN) to me;
2. The University of Adelaide will disclose this information to the Department of Education and Training (DET) for those purposes;
3. DET will store this information securely in the Higher Education Information Management System;
4. DET may disclose the information to the Tax Office; and
5. The University of Adelaide and DET will not otherwise disclose this information without my consent unless required or authorised by law.

Note: This form will not submit if the total file size of all combined file attachments is over 20MB.