Student enrolment form

Personal details

Title:	.
Surname:	.
First Names:	.
Preferred First Name:	.
Previous Name (if different)	.
Date of Birth:	.	Gender: Male [ ] Female [ ]
Programme Name:	.

Please complete
if you can

Student ID
[_______________]

NZQA ID
[_______________]

Other Tertiary Inst. ID
[_______________]

Address details

Home Postal Address

Term Postal Address (if different)

Telephone No. ( )

Contact Fax No. ( )

Telephone No. ( )

Contact E-mail:

Study contract details

How do you intend to pay for your study?		Do you intend to finish your study this year? Yes [ ] No [ ] Returning students: Have you been a full-time student at XXX Institute? (i.e. a returning student) Yes [ ] No [ ]
[ ]	Student Loan Scheme
[ ]	Cash
[ ]	Cheque
[ ]	NZ Income Support Training Incentive Allowance
[ ]	ACC

Citizenship details

Tick the box that best describes your citizenship or permanent residence status.
You are required to produce your Birth Certificate or other evidence of permanent residence to verify your status as a Domestic student.

NZL [ ] NZ Citizen
NZP [ ] NZ Permanent Resident

AUS [ ] Australian Citizen
Other[ ] (Specify) [________________________]

Ethnic origin

[   ] 01 New Zealander/European/Paheha
[   ] 02 NZ Maori
[   ] 31 Samoan
[   ] 32 Cook Island Maori
[   ] 33 Tongan

[   ] 34 Niuean
[   ] 35 Tokelauan
[   ] 36 Fijian
[   ] 37 Other Pacific Islander   [_______________]

[   ] 51 Chinese
[   ] 52 Indian
[   ] 68 Other Asian [_____________]
[   ] 89 Other (Specify) [_______________]

Emergency contact details

Contact person in case of an emergency

Name:

Relationship:

Address:

Home telephone: ( )

Work telephone: ( )