Given names *

Given name is the name as it appears on the student's birth certificate and identification

Family Name*

The student's family or surname

DOB*

The Date of Birth of the student

Gender*

• Male

• Female

• Not Stated

• Indeterminate /Intersex / Unspecified

Student No*

An institution allocated Unique student identifier

Title*

• Mr

• Mrs

• Miss

• Ms

• Dr

• Rev

CRICOS Provider Code*

The Commonwealth Register of Institutions and Courses for Overseas Students (CRICOS) is a register of Australian education providers that recruit, enrol and teach overseas students. Registration on CRICOS allows providers to offer courses to overseas students studying in Australia on student visas.

Name (Provider)*

The Full and Legal name of the Institution to appear on official documents

CRICOS Code*

CRICOS Course Code

Name (Course)*

The Full name of the Course of Study

Start Date*

Start date of the Course of Study

Expected End Date*

Expected / Estimated end date of the Course of Study

Agent*

Date From

Commencing Date of Leave

Date To

Final Date of of Leave

Reason

• Family

• Illness

Absence Type

• Leave

• Deferral

Status

• Approved

• Denied

• Pending

Staff Member Approved

Name of Staff member who approved the leave

Approved Date

Date the Leave was approved

Comments

Any additional comments / notes