Biomedical Science (Medical) Rurality form 1. My detailsGiven name * Family name * Date of birth * Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJuneJulyAugSeptOctNovDec Year 19701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010 Current street address * Suburb/City/Town * State * -- Please Select -- VIC ACT NSW NT QLD SA TAS WA Postcode * Phone * Personal email address * (NOT school email) VTAC/UAC application ID * 2. Rurality evidence Category * -- Please Select --5 years consecutive10 years cumulative Time period #1Date claim commencing * Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJuneJulyAugSeptOctNovDec Year 1970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099 Date claim concluding * Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJuneJulyAugSeptOctNovDec Year 1970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099 Street address Suburb/City/Town State VIC ACT NSW NT QLD SA TAS WA Postcode Date1 evidence * Click (+) to upload another file. (jpg, pdf or png file type ONLY. Max 8MB file size) Time period #2Date claim commencing Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJuneJulyAugSeptOctNovDec Year 1970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099 Date claim concluding Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJuneJulyAugSeptOctNovDec Year 1970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099 Street address Suburb/City/Town State VIC ACT NSW NT QLD SA TAS WA Postcode Date2 evidence Click (+) to upload another file. (jpg, pdf or png file type ONLY. Max 8MB file size) Add another time period Time period #3Date claim commencing Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJuneJulyAugSeptOctNovDec Year 1970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099 Date claim concluding Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJuneJulyAugSeptOctNovDec Year 1970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099 Street address Suburb/City/Town State VIC ACT NSW NT QLD SA TAS WA Postcode Date3 evidence Click (+) to upload another file. (jpg, pdf or png file type ONLY. Max 8MB file size) 3. Rurality statements Please provide TWO statements to show your commitment to community. Each statement is limited to 700 characters. If you are invited to an interview, your statements will be used to inform the interview questions. De-identified responses may also be used for research and evaluation to improve selection into medicine. Statement #1 Describe ONE community that you identify with. * NOTE: A community may be defined by a place, or by its people. Please include your regional and/or rural community (Max 700 characters) Statement #2 Explain ways in which you connect with the community you described in Statement 1 * (Max 700 characters) 4. Academic transcript Are you applying as a non-year 12 applicant with tertiary study? * No Yes Upload a high-quality colour scan of your official academic transcript demonstrating 1 year effective full time study load for tertiary study. Ensure that: you are scanning original, official documentsyour scans are high quality, clear, easy to read and in colouryour documents are scans and not photographs (you can use a scanner app on a phone)the scans are not askew or poorly focused as these will be rejected Transcript Click (+) to upload another file. (jpg, gif, pdf or png file type ONLY. Max 8MB file size) If the personal details you provided above are different to your academic transcripts, please attach proof of change of personal details. Change of personal details Click (+) to upload another file. (jpg, gif, pdf or png file type ONLY. Max 8MB file size) School Endorsement Form (jpg, gif, pdf or png file type ONLY. Max 8MB file size) Year 11 Transcript Click (+) to upload another file. (jpg, gif, pdf or png file type ONLY. Max 8MB file size) Declaration I have attached acceptable documentation that supports living rurally for 5 years consecutively or 10 years cumulatively. I have completed the personal statement(s). To the best of my knowledge, the information given in this application is correct and complete. I understand that submitting false or misleading information may result in any offer of a place withdrawn at any stage, including after a course has commenced. I understand the University reserves the right to vary or reverse any decision made on the basis of incorrect or incomplete information. The University is under no obligation to consider any application submitted after the due date. I authorise La Trobe University to seek and obtain official records pertaining to me from any educational authority holding such records either directly or via electronic request. I acknowledge and accept the full enrolment terms and conditions that govern this application form. I accept the terms and conditions * PrivacyLa Trobe University respects the privacy of your personal information and your privacy is important to us. Information collected on this form will only be used by the University for the purposes related to assessing your application and in accordance with the Website Privacy Statement and the University's Privacy Policies. You may have the right to access the personal information we hold about you subject to any exemptions in relevant laws by contacting us on 03 9479 1839.Validation