AGENT
DATA ENTRY FORM
This form is for UWA representatives to record student information to then enter into UWA’s online application portal.
If you wish to apply to UWA, please fill out the details and supply this form to an official UWA representative.
For a list of official UWA representatives near you visit study.uwa.edu.au/how-to-apply/international-agents
This is NOT an application form. Please do not send this form to UWA.
APPLICANT DETAILS
Family name
Given name
Preferred name
Title Date of birth (dd|mm|yyyy) | | Gender M F
Telephone number
Email address
(compulsory)
Residential address (Number and Street, Suburb, State, Country and Postcode)
Mailing address (Number and Street, Suburb, State/Region, Country and Postcode)
CITIZENSHIP AND VISA DETAILS
Country of birth Country of c itizenship
Passport number
Type of visa you are applying for International student visa Temporary resident Other (please specify)
Country of visa application City of visa application
APPLICATION DETAILS
Have you previously studied at UWA? Yes No Student number
Have you lodged any other application to UWA for the period in which you intend to apply? Yes No
Have you previously been offered and deferred the course for which you intend to apply? Yes No
Do you wish to apply for a packaged English language program with your course? Yes No
COURSE PREFERENCES
CHOOSE INTAKE Year February (Semester 1) July (Semester 2)
Course 1 (Name, Code, Major/Specialisation)
Course 2 (Name, Code, Major/Specialisation)
UNDERGRADUATE APPLICANTS ONLY
A: If you would like a packaged offer which includes a postgraduate professional degree following your bachelor’s degree,
please indicate below.
Master of Architecture (MArch) Master of Landscape Architecture (MLarch)
Master of Professional Engineering (MPE) Juris Doctor (JD)
Doctor of Medicine (MD) Doctor of Dental Medicine (DMD) I do not wish to apply for direct entry
note: please check closing dates for the doctor of medicine (md) and doctor of dental medicine (dmd).
AGENT
DATA ENTRY FORM
This form is to record student information to then enter into UWA’s online application portal www.uwa.edu.au/agents/myapplication
This is NOT an application form. Please do not send this form to UWA.
B: If your academic background is assessed by the University as not sufficient for direct entry, you may be eligible for a pathway program.
If you would like your application to be forwarded to one of our pathway partners to be considered for a packaged offer (i.e. Foundation or
Preparatory program + UWA degree) please indicate your preference below.
WA Universities’ Foundation Year Program (WAUFP) UWA Foundation Program
FINANCIAL SUPPORT
Select your source of financial support:
Privately funded Employer sponsored Government sponsored (provide details) External scholarship (provide details)
Details of sponsorship or scholarship (organisation, country)
SECONDARY EDUCATION DETAILS
Country of secondary education Year completed
Qualification name
School Score
TERTIARY EDUCATION DETAILS
Qualification name
Year commenced Year completed Incomplete
Institution
OTHER QUALIFICATION(S)
Qualification name
Date completed (dd|mm|yyyy) | |
Details
WORK EXPERIENCE (CHECK TO SEE IF REQUIRED BY COURSE)
Position
Employer
Start date (dd|mm|yyyy) | | End date (dd|mm|yyyy) | |
Contact (address | telephone | email)
ENGLISH COMPETENCY
Type of test
Year achieved
Score/Grade
CRICOS Provider Code: 00126G UniPrint 119624
