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1. Your occupation
1.1 Title
CA-1Application for Competency Assessment
Barcode (Office use only) Receipt number (Office use only)
2. Your personal details
2.2 Date of birth
/ /
Day Month Year
2.3 Name
Given names
Previous surname or family name (if applicable)
No family nameSurname or family name
FemaleMaleOtherMrsMr Ms Miss2.1 Preferred title
Please read the Explanatory Notes at www.vetassess.com.au before you complete this form.1
Make sure you provide all documents required and sign the photo and declaration.2
When printing this form, set Page Scaling to None in the Print dialog windowIn Adobe Acrobat Reader, see: File > Print > Page Scaling in the Page Handling section
4
To complete the form, please use a black pen and print clearly in BLOCK LETTERS as shown in the example below:3
Mark answer boxes with a cross . If you make a mistake, fill in the entire box and mark the correct box
J O H N S M I T H
Important information about how to complete and print this form
File number (Office use only)
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2.7 Postal address(address where you want
your mail sent this maybe your agent)
PostcodeState
Country
Suburb or town
Postal address
2.8 Home address(if different from your
postal address)
PostcodeState
Country
Suburb or town
Home address
2.4 Country of birth
2. Your personal details continued
2.9 Contact details
Telephone number
Fax number
Mobile phone number
Email address
2.5 Residency status Are you an Australian citizen or permanent resident?
What is your country of citizenship?
Passport number
No
Yes
2.6 Migration Visa If you need a skills assessment for migration purposes, indicate the visa pathway you intend to take.
GSM
ENS
457 Visa
Other
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3. Authorising an agent
3.2 Name of agent or
representative
3.3 Agents company name(if applicable)
3.4 Agents MARA number(if applicable)
Give details below
3.5 Contact details of agent orrepresentative
Telephone number
Fax number
Mobile phone number
PostcodeState
Country
Suburb or town
Address
TRAINING
4. Your general school education
4.1 Secondary and/ortechnical education Number of years
/
Month YearStarted:
/
Month YearFinished:
Name of highestschooling certificate
obtained
Country of education
Email address
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3.1 Do you authorise an agentor representative to act foryou in matters concerningthis application (this canbe a family member or amigration agent)
No
Yes
Go to Section 4
I authorise the agent or representative below to act for mein all matters concerned with this application.
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5. Your formal training
No
Yes
5.2 Was this part of anapprenticeship?
5.3 Occupation/Trade
5.4 Name of training program
5.6 Dates of training(or apprenticeship) Number of years
/
Month YearStarted:
/
Month YearFinished:
5.5 Apprenticeship/Traineeship(complete only if yourtraining was part ofan apprenticeship/traineeship)
Name of authority
5.7 Entry requirements
(if relevant)
5.9 Type of trainingFull time study
Part time study
5.8 Course duration Total number of years
Employer/Employmentcontract
PostcodeState
Country
Suburb or town
Address
Company name
Give details below
No
Yes
Go to Section 65.1 Have you completed any
formal training?
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5. Your formal training continued
Campus
PostcodeState
Country
Suburb or town
Address
Name5.10 Training instituteattended
Date completed
/
Month Year
Name5.11 Final exam(if applicable)
5.12 Title of qualificationobtained
5.13 Name of awardingauthority
You will need to attach evidence of completion of this training to your application to page 14.
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6. Other training (e.g. company training, short courses etc)
Dates of training
/Month Year
Started:
/Month Year
Finished:
Name of program
Training institute orcompany
PostcodeState
Country
Suburb or town
Address
Name
Type of trainingFull time study
Part time study
Training duration Course hours
Give details below
No
Yes
Go to Section 76.1 Have you undertaken any
other training programs?
You will need to attach evidence of completion of this training to your application to page 14.
Title of qualificationobtained
Name of awardingauthority
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PROGRAM 1
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6. Other training (e.g. company training, short courses etc) continued
Dates of training
/
Month YearStarted:
/
Month YearFinished:
Name of program
Training institute or
company
PostcodeState
Country
Suburb or town
Address
Name
Type of trainingFull time study
Part time study
Training duration Course hours
You will need to attach evidence of completion of this training to your application to page 14.
Title of qualificationobtained
Name of awardingauthority
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PROGRAM 2
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7. Licensing, registration and/or industry membership
Give details below
No
Yes
Go to Section 87.1 Do you hold an
occupational licence,registration or industrymembership?
7.2 Occupation or industryarea
7.4 Title of licence,registration or industrymembership
7.3 Issuing authority
7.5 Description of what thelicence, registration ormembership entitles you
to do
7.6 Dates
/
Month YearIssued:
/
Month YearValid to:
You will need to attach evidence of licence, registration and/or industry membership toyour application to page 14.
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WORK EXPERIENCE
8. Your employment history
YesNo8.2 Are you self-employed?
8.1 Work experience in tradearea
How long have you been working in the trade area you have nominated in this application?
MonthsYears
Your occupation and/orposition held withemployer
8.3 Employment history
EMPLOYER 1Employer name andcontact information
PostcodeState
Country
Suburb or town
Address
Telephone number
Fax number
Contact person
Email address
Company name
Period in occupation
/
Month YearFrom:
/
Month YearTo:
You will need to attachevidence of employmentto your application to p14.
PostcodeState
Country
Suburb or town
Address
EMPLOYER 2Employer name andcontact information
Company name
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8. Your employment history continued
Your occupation and/orposition held withemployer
Period in occupation
/
Month YearFrom:
/
Month YearTo:
Telephone number
Fax number
Contact person
EMPLOYER 2Employer name andcontact informationcontinued
Your occupation and/orposition held withemployer
Period in occupation
/
Month YearFrom:
/
Month YearTo:
You will need to attachevidence of employmentto your application to p14.
You will need to attachevidence of employmentto your application to p14.
EMPLOYER 3Employer name andcontact information
PostcodeState
Country
Suburb or town
Address
Telephone number
Fax number
Contact person
Company name
Email address
Email address
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9. Other information (the following information is required for enrolment and qualification completion purposes)
9.1 Are you of Aboriginaland/or Torres StraitIslander origin?
No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, Aboriginal and Torres Strait Islander
9.2 Do you speak a languageother than English athome? Which language do you speak at home? If more than one language, please
specify the language that is spoken most often.Yes
No, English Only
9.3 Do you consider yourselfto have a disability,impairment or long termcondition?
Please indicate the area(s) of disability, impairment or long term condition.(Select ALL that apply)
Hearing/Deaf
Physical
Intellectual
Learning
Mental Illness
Acquired Brain Impairment
Vision
Medical condition
Other
No
Yes
9.4 Which of the followingcategories BEST describesyour current employmentstatus?(Select one)
Full-time Employee
Part-time Employee
Self-Employed Not Employing Others
Employer
Employer Unpaid Worker in a Family Business
Unemployed Seeking Full-Time Work
Unemployed Seeking Part-Time Work
Not Employed Not Seeking Employment
9.5 Please indicate if you haveSUCCESSFULLY completedany of the followingqualifications.(Select ALL that apply)
Bachelor Degree or Higher Degree
Advanced Diploma or Associate Degree
Diploma or Associate Diploma
Certificate IV or Advanced Certificate/Technician
Certificate III or Trade Certificate
Certificate II
Certificate I
Certificates other than the above
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10. Required Document Checklist
I have included: Identity documents
Certified copy of my Australian drivers licence or relevant biography page from my passport or mybirth certificate
Evidence of change of name (where applicable)
Two (2) recent passport size photographs, certified as a true likeness of myself
Training documentsCertified copy of my training qualifications/certificates in the original language
Certified copy of the transcript or record of results showing subjects, examination results and/orgrades/marks in the original language (where applicable)
Certified copies of any other relevant training
Certified copy of licences, registration or industry membership documentation
Work experience
Original or certified copies of evidence of work experience
Please ensure you have included certified true copies.
Original documents for work experience will be accepted.
Documents will not be returned.
Other
Trade Evidence form for my nominated occupation
Correct payment
Certified translations in English of any of the above documents originally issued in a language otherthan English
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11. Applicants declaration
Please use a paperclip to attach two (2) certified photographs of yourself here.DO NOT STAPLE
I have read and abide bythe above declaration
/ /
Day Month Year
Applicants signature(agents DO NOT sign on behalf of applicant)
Office Use Only Office Use Only
I (print name) declare that:
The information I have supplied on this form and in attachments is complete, correct and up to date.
I have included the required documents as listed on the Required Document Checklist.
All the evidence I have provided relates to me and my work and can be verified.
I have read and understood the information supplied to me in the Explanatory Notes accompanyingthis application.
I will inform VETASSESS of any changes to my circumstances in writing (e.g. change of address) whilemy application is being considered.
I authorise my appointed agent or representative to act in all matters concerned with this application.
I authorise VETASSESS to make any enquiries necessary to assist in the assessment of my skills(including contacting training institutions, employers or other authorities) and to use any informationsupplied for that purpose.
I understand that VETASSESS may verify information relating to this application with any Australianstate or territory licensing or training authority.
I understand that VETASSESS may provide the Department of Education, Employment and WorkplaceRelations (Australia); Department of Immigration and Citizenship (Australia); or the Australian TaxationOffice with any of the information supplied in this application.
I understand that documentation and information submitted in support of my application may bereferred to the Department of Immigration and Citizenship (Australia) for integrity checking.
I understand that my photograph may be taken and/or videotaping/recording may occur during theassessment. This may be used for identity checking and/or for assessment moderation purposes.
I understand that information collected through the assessment process may be provided to Australianstate and federal government for the purposes of statistical data collection.
* I acknowledge that I am undertaking the practical assessment at my own risk and that it is myresponsibility to adhere to safe work practices during the schedules practical assessment. I acknowledgethat it is my responsibility to ensure that at all times during the assessment activities that I worksafety when working on my own and when working with others, and while using any tools andequipment. I agree that VETASSESS and any third party providing services in respect of or hosting theassessment is not liable in respect of any personal injury, death or property damage arising duringthe course of the assessments.
* I have read the information in the Explanatory Notes and/or on the VETASSESS website regarding feesand conditions for assessment, reassessment, review and appeal.
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12. Fees and payment
12.1 I am paying my fees byCredit card Bank draft or bank cheque Money order
Please note that theapplication fee is notrefundable
Credit card typeMasterCard
VISA
Authorisations missing any of the above information will not be processed.
Signature of cardholder
/ /Day Month Year
Name of cardholder
Credit card validationcode
(the last three digits of the number printed on the signature panel)
Credit card
/
Expiry dateNumber
authorise VETASSESS to debit my credit card for the amount of:
as payment for the processing of my Application for Skills Assessment. I understand that the fee isnon-refundable.
12.3 Credit card payment
I,
Name of cardholder
12.2 Amount payable
Calculate the total amountpayable before you makeyour payment
Australian citizen orpermanent resident
Non-citizen ornon-permanent resident
Postage (if applicable)(Select one only)
=
Note: If you select fullpayment but areunsuccessful in meeting therequirements to progress tostage two of the assessment
process, you will receive arefund to the value of thestage two assessment fee.
If you select the two stagepayment, you will beinvoiced for the remainingassessment fee uponsuccessful completion ofstage one of the assessment
process.Registered Australian mail AUD $5.00
Express Post International AUD $16.00(not traceable outside Australia)
Express Courier International AUD $34.00(traceable in major cities outside Australia)
Full payment
Two stage payment
AUD $1200.00
AUD $600.00
Full payment
Two stage payment
AUD $950.00
AUD $400.00
AUD $ 0 0
AUD $ 0 0
AUD $ 0 0
AUD $ 0 0
AUD $ 0 0
TOTAL Amount Payable(add all the above amounts)
AUD $ 0 0
AUD $ 0 0
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After the first stage of the assessment is completed, you will receive further information from VETASSESS explaining stage two of theassessment process.
14. Next stage: Practical Assessment/Technical Interview
13. Submit application
Post your application, withall required documentationand fees, to:
QualityEndorsedCompanyISO 9001 QEC23802
SAI Global
TM
VETASSESSSkills Recognition NationalPO Box 2752
Melbourne VIC 3001Australia
Please indicate where you want to be assessed.
At work
At a TAFE institute
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