Please complete the form below to apply for the Academic English program at the Centre for English Language.

Course Details

This application form is for the CELUSA Academic English (AE) program

Select the education provider you wish to package your AE program with:

Select your start month:

Select your start year:

Your personal details

Title:

Other

First Name:

Last Name

Gender:

Male

Female

Date of Birth:

Country of Birth:

Are you an Australian citizen or permanent resident?

Yes

Student Personal Contact details:

Email Address:

Home Telephone:

Mobile Phone:

Address Details:

Please provide full address including: Street number, Street name, Suburb, Postcode, City, Country, etc

Passport Details

Passport Number:

Passport Expiry Date:

English Proficiency:

Have you completed an IELTS or TOEFL test?

Yes

IELTS

TOEFL

Other English Test Score

Student Health Insurance:

Do you wish us to have arrange OSHC Worldcare policy for you?

Yes

OSHC Worldcare Policy Details – OSHC Required

If no, what is the name of your OSHC provider?

If no, OSHC number:

Your Agent/Representative's Details

Are you enrolling through an agent/representative?

Yes No

If yes, name of agent/representative:

Agency contact person:

Agent email address:

Agent telephone:

Agent address:

Please provide full address including: Street number, Street name, Suburb, Postcode, City, Country, etc

Others:

Request for homestay?

Yes No

Request for airport pickup service?

Yes No

Request for disability support?

Yes No

If Yes, please provide details:

Are you being 'sponsored' by an individual or organisation?

Yes No

If Yes, please provide details

Supporting Documents

Please indicate what test/s you have sat (or intend sitting) and attach certified* documentary evidence of results. A certified copy, is a copy of an original document that has been certified as a true and correct copy by a person who is authorised to witness a statutory declaration.

Add another attachment

Declaration

I declare that the information I have supplied in this form is, to the best of my understanding and belief, complete and correct.

Yes