SCHOOL OF MEDICINE Rural Application Process – Application Form Bachelor of Medicine/Bachelor of Surgery (MBBS) 2017 entry Closing Date for applications: Friday, 30th September 2016 Applications received after the closing date will not be accepted. Please complete the following form and send to [email protected] If you need assistance filling in the form, please email [email protected]

What is the Rural Application Process?

The Rural Application Process aims to support students from regional or remote areas of Australia to study medicine. The benefits of applying through the Rural Application Process may include: - Consideration of your rural background during the application process - Access to the Tasmanian Medical Student Rural Application Process Funding Scheme Grant Students applying to medicine through this process must also apply centrally through the usual University of Tasmania application process, and will be assessed for both a rural place as well as a regular MBBS position. If you live in a rural area of Australia, you may be eligible to apply via the Rural Application Process. Eligibility is based on location. You must have lived in a regional or remote area of Australia prior to commencing medical school training for:  Five or more consecutive years, OR

 Ten cumulative years Search for your regional or remote location(s) on the Doctor Connect website for the Australian Standard Geographical Classification for Remoteness Area. A regional or remote area of Australia is defined as Remoteness Area categories RA2-RA5. Please note this is a Government defined definition. All of Tasmania is defined as RA2-RA5.

☐ I am eligible as per the above definition to apply through the Rural Application Process ☐ Yes, I have applied for MBBS. If not, please apply here www.utas.edu.au/admissions/how-to-apply

1 of 6 Part 1: Personal Details Title Enter title.

First Name Enter first name. Family Enter family name. Name

Date of Birth Click here to enter a date.

Address Enter address

Suburb Suburb. State State Postcode pcod e

Email Enter email.

Home Phone (inc. Eg 03 6222 2222. Mobile Eg 0412 345 678. area code)

Sex Click to choose an option.

Citizenship Status Click here to enter text.

University Application Enter University Application Number. Number

Preferred time of contact (AEDST): ☐ 0900 - 1200 ☐ 1200 - 1400 ☐ 1400 - 1730 ☐ 1730 - 2000 Preferred method of contact: ☐ Mobile ☐ Home phone ☐ Email

Are you currently or have you ever been a University of Tasmania student? Choose an option. If yes, please state your student number - Enter Student ID Are you of Aboriginal or Torres Strait Islander origin? Choose an option. If yes, you may be eligible for the Aboriginal Entry Application Process

2 of 6 Part 2: Rural Applicants Supporting Documentation Please demonstrate you have lived for 5 years consecutively or 10 years cumulatively in a rural area by listing the locations below.

Years Address Postcode Eg. 2005-2007 23 Brickport Rd, Burnie 7310

Primary School Location Year of schooling Name of School Address of School (e.g. - 2001 – Prep) Eg. 1999-2003 Burnie Primary 15 Van Diemens Crs, Burnie School

Secondary School (High School / College) Location Year of schooling Name of High Address of School (e.g. - 2005 – Yr 7) School / College Eg. 2005-2007 Burnie High School 30 Fidler St, Cooee

Please list any tertiary studies you have undertaken (list years, qualification gained or worked towards and institution):

3 of 6 Year Qualification Institution Status started Eg. 1997 Diploma Business Studies Monash University Deferred

4 of 6 Part 3: Personal Statement Please answer the following questions; Why do you want to become a doctor? (200 word maximum) Click here to enter text.

How will this enable you to contribute to your community? (300 word maximum) Click here to enter text.

Which 3 personal characteristics do you believe will help you become a good doctor? Please give an example of how you have used this in the past (300 word maximum) Click here to enter text.

5 of 6 Declaration: The University of Tasmania collects, stores and uses personal information, including student images, for the purposes of: • administration of the student's enrolment and progress in their study; • the provision of other services to the student by the University; and • to comply with the Higher Education Support Act 2003, the Education Services for Overseas Students (ESOS) Act 2000 and the National Code of Practice for Registration Authorities and Providers of Education and Training to Overseas Students 2007. All information and images are collected and stored on a secure server; only accessed by University staff for the purposes for which they have been collected; and will only be used or disclosed in accordance with the University of Tasmania Privacy Policy at http://www.utas.edu.au/policy . I understand that • I have the right to access my personal information held by the University in accordance with the Right to Information Act 2009 (Tas); • I may make a Right to Information request to access my information and I am able to do so by following the information provided at www.utas.edu.au/legal-services/right-to-information-act; • It is my responsibility to ensure that my enrolment is correct by the census date; • I agree to pay all fees, levies and charges within the specified timelines; • I will receive information and notices in relation to my course of study or general information via my University e-mail account; • I am required to abide by the University Ordinances, Rules, Policies and procedures; • I am aware of the conditions under which I can use the University's Information Technology facilities and I accept responsibility to obtain and read the relevant documents; • I understand that the email service may be delivered using cloud services from another provider with data centres hosted overseas; • I consent to UTAS disclosing my personal information to a person or body external to UTAS where disclosure is: • required by law, or permitted by law or is required to fulfil necessary reporting requirements to Commonwealth and/or state departments, or statutory bodies, • is made necessary for reasons associated with my enrolment at UTAS, and for the purposes of: o other institutions involved in the delivery of my course of study, o providing me with careers advice, services and development, which will benefit me as a student, o disclosure to external organisations such as professional bodies, if the disclosure is necessary to undertake learning in a workplace, o providing information to third parties contracted to administer surveys of students and graduates on behalf of the University o being part of the UTAS Alumni database upon graduation to foster alumni relations, o of being part of the UTAS Advancement Office database to engage with and support the university in the future, and, o any other circumstances in accordance with the UTAS Privacy Policy at www.utas.edu.au/policy • I authorise UTAS to obtain official records from any educational institution I have attended to enable my application to be considered. Where necessary QualSearch will be engaged to access this academic information. I understand that UTAS is not responsible if any educational body/ institution does not supply these records. I understand that the results of the search will be made available to me on request and that an audit of this authority may also be undertaken; and • I acknowledge I have read and understood the University's Privacy Policy.

☐ I declare to the best of my knowledge and belief that the information given in this form is correct and complete in every detail

Please send your completed form to [email protected] You will receive acknowledgement of receipt within 7 days. Please ensure you add this email to your contacts. Otherwise, the email may go to your ‘Junk’ folder.

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