Professional Year Program (I
CT) Application Form V3.4
QIBA Pty Ltd | CRICOS Provider Code: 01515J | RTO Code: 5304 | ABN: 35 071 667 108
PROFESSIONAL YEAR PROGRAM
APPLICATION FORM
ICT - 2022
PERSONAL DETAILS
Title Mr Mrs Ms Miss Other
Family name
Given name(s)
Single name only
(tick this box if you have a single name. If this is the case, Include your single name in
the ‘Family name’ field).
Date of Birth Gender: Male Female Other
CONTACT DETAILS
Address
Unit/Flat details
Street
Suburb
State/Territory Postcode
Postal Address (if
different from above)
Contact Number(s) Home: Mobile: Work:
Email Address
EMERGENCY CONTACT DETAILS
Name Relationship
Address
Contact Number Email Address
PASSPORT AND VISA DETAILS
Country of Birth Country of Citizenship
Passport Number
Do you hold a 485 Visa? Yes
No
If Yes, Expiry Date
If No, have you applied?
I hold another Visa Visa Type:
Yes
Professional Year Program (I
CT) Application Form V3.4
QIBA Pty Ltd | CRICOS Provider Code: 01515J | RTO Code: 5304 | ABN: 35 071 667 108
DISABILITY (Please select the relevant boxes)
Do you have a disability, impairment or long-term condition? (Please
select the relevant box)
Yes No
If YES, then please indicate the areas of disability, impairment or long-term condition.
Hearing/deaf Learning Vision
Acquired Brain
Impairment
Physical Mental Illness Mobility Medical Condition
Intellectual Other (please specify)
COVID-19 VACCINATION STATUS
All applications for enrolment must now include the applicant’s vaccination status as part of the QIBA
application process. Evidence (i.e., a Vaccination Certificate or medical exemption) must also be provided
as part of this submission to support the answers provided below.
Vaccinated (COVID-19) Fully vaccinated Received first dose
Unvaccinated Yes
If Yes, to unvaccinated, do you have a Valid Medical Exemption? Yes No
AUSTRALIAN EDUCATION DETAILS
Have you completed ICT qualifications? Yes No
Date Commenced Date Completed Course Name Institute
ENGLISH PROFICIENCY
ICT APPLICANTS REQUIRE AN ELT SCORE WITH NO BAND BELOW 6 (IELTS or EQUIVALENT)
Test IELTS PTE TOEFL
Date of Test Overall Score
Component score Writing Reading Speaking Listening
PROFESSIONAL YEAR PROGRAM LOCATION PREFERENCE
Brisbane (CBD) Sydney (CBD) Canberra Hobart
Gold Coast
Preferred Intake Date
Professional Year Program (I
CT) Application Form V3.4
QIBA Pty Ltd | CRICOS Provider Code: 01515J | RTO Code: 5304 | ABN: 35 071 667 108
ICT APPLICANTS - SUPPORTING CERTIFIED DOCUMENTS
Passport Skilled Graduate 485 Visa English Proficiency Results
Academic Transcript Course Completion Letter COVID-19 Vaccine Certificate
ICT APPLICANTS - PAYMENT OPTIONS
Upfront payment Instalment payment (6 instalments)
HOW DID YOU LEARN ABOUT QIBA?
Agent Friend Google Search Social Media Event/exhibition Other
AGENT INFORMATION (if applicable)
Name of Agency
Agents Name
Agents Contact Details
FOR APPLICATION ASSISTANCE
QIBA Professional Year Program
t 02 9267 3040 e py.enrolments@qiba.edu.au e marketing@qiba.edu.au
DECLARATION
I declare that the information supplied by me on this form is true and correct.
I ack
nowledge that QIBA reserves the right to vary or reverse any decision regarding admission based on incorrect or
incomplete information.
I have read and understand the QIBA terms and conditions as explained in the following link
PYP-Terms-and-
Conditions-V9.2.pdf (qiba.edu.au) and am fully aware of the following:
QIBA will make no refund of tuition fees once the course begins.
Students using the instalment option for payment of tuition fees that choose to withdraw from the
course after it has begun are liable for full tuition fees. Finalisation of the account must be by the date
stipulated on the agreed instalment plan. Failure to do so will result in legal action and outstanding fees
will be referred to an external collection agency as outlined in the terms and conditions.
I understand that I must complete a face-to-face Pre-Enrolment interview, plus an online Orientation,
prior to being eligible to commence on the scheduled start date.
Applicants must demonstrate that their Australian ICT qualification is closely related to their future nominated
occupation (ANZSCO). Per ACS Skills Assessment Guidelines for Applicants, at least 65% of the ICT content must be
closely related to the nominated occupation.
Professional Year Program (I
CT) Application Form V3.4
QIBA Pty Ltd | CRICOS Provider Code: 01515J | RTO Code: 5304 | ABN: 35 071 667 108
I u
nderstand that completion of the Professional Year Program does not guarantee permanent residency in Australia
and such decisions are at the discretion of the DHA alone.
I DECLARE I HAVE READ THE ABOVE TERMS AND CONDITIONS AND COMPLETELY UNDERSTAND MY
OBLIGATIONS.
Applicants Full Name
Date of Application
Submitted by Self Agent
Agent Contact Number
Applicants Signature
(use either field)
click to sign
signature
click to edit