On-Line Clinical Psychology Program Application

Please complete all sections of this form and click submit.

This form is only part of the application process. You should consult: http://www.uow.edu.au/health/psyc/clinical/UOW024839.html for details of the other application requirements. You cannot change the details of this form once it has been submitted.

Personal and Contact Details
Title:
Last Name:
First Name:
Date of Birth:	/ /
UOW Student No: (if known)
Street Address:
Suburb:
State:
Post Code:
Country:
Will this be your mailing address up to the end of the current calendar year?	Yes No
Email Address:
Daytime Contact Number:
Mobile Phone Number:
Are you an international student?	Yes No
Gender:	Female Male
Ethnicity:
Languages spoken other than English:
Course(s) applied for:	Master of Psychology (Clinical) DPsyc PhD
Qualifications
Please enter your university qualifications in chronological order
Bachelors Degree:
Major:
University:
Year Completed:
4th Year Degree:
University:
Honours Grade (if applicable):
Year completed (if you are finishing this year, enter "in progress":
If you completed your degree at an overseas university, have you had it assessed and approved by the Australian Psychological Society? If not, you should arrange this BEFORE submitting your application to the UOW. See Psychology.org.au Membership qualifications	Yes No
Other university degrees (e.g. PhD, Masters)
University:
Year Completed:
Other Qualifications:
Are you a registered psychologist?	Yes No
Which Australian State or Territory are you registered in?
Enter any other qualifications here:
Relevant Experience
Please enter up to four examples of work experience that you believe are relevant to your suitability for clinical psychology training
Employer:
Was this paid or voluntary employment?	Paid Voluntary
Start Date:	/ /
Finish Date (leave blank if ongoing):	/ /
Employer:
Was this paid or voluntary employment?	Paid Voluntary
Start Date:	/ /
Finish Date (leave blank if ongoing):	/ /
Employer:
Was this paid or voluntary employment?	Paid Voluntary
Start Date:	/ /
Finish Date (leave blank if ongoing):	/ /
Employer:
Was this paid or voluntary employment?	Paid Voluntary
Start Date:	/ /
Finish Date (leave blank if ongoing):	/ /
Referees
Your referees should complete their report independently and send it directly to the School of Psychology. Full instructions are on the referee form.
Referee 1
Last Name:
First Name:
Email Address:
Phone Number:
Context in which this referee knows you (e.g. employer, university lecturer):
Referee 2
Last Name:
First Name:
Email Address:
Phone Number:
Context in which this referee knows you (e.g. employer, university lecturer):
Publications and Conference Presentations
Please enter any publications that you have authored or co-authored here:
Please enter any conference presentations that you have authored or co-authored here:
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