Family Name:
Given Name:
Home Address:
Telephone:
Mobile:
Email:
Date of Birth:
Gender:	Male Female
What is the name of your next of kin?
What is their telephone number?
Are you registered with Centrelink?	Yes No
If yes, name of benefit/allowance?
Are you registered with a Job Network?	Yes No
If yes, name of Job Network
Do you a current drivers’ license?	Yes No
Do you have a disability that effects your ability to work/train/study?	Yes No
How did you find out about us?	Please select... Organisation Referral Newspaper Radio TV Web Word of Mouth Other... If you selecter 'Other...', please describe:

Education

Year of schooling completed		Yr 8, Yr 9, Yr 10, Yr 11, Y 12
What year did you complete school?
Have you completed further education? (TAFE, Job Network, CDEP etc) Please give course details
Name of Course	Institution	Date Complete	Subject or Qualification

Employment History

Do you have a resume?	Yes No
Last Job:
Employer Name:
Position Held:
Period of Employment:
Duties:

Referees

Please provide contact details for two referees below
(referees may be previous employer, Aboriginal education workers, teacher, youth worker etc)

Referee 1
Name:
Position:
Organisation:
Phone:
Mobile:
Email:
Referee 2
Name:
Position:
Organisation:
Phone:
Mobile:
Email:

Participant Declaration

I Certify that:

The information supplied above is correct:

• I am an Indigenous Australian
• I normally reside in a remote location (according to the ARIA classification)
• I am voluntarily participating in the Indigenous Success Australia/DEST Indigenous Youth Mobility Programme

I hereby authorise ISA to keep information and documents provided by me on its registers of information and to make the information and documents available (either electronically or manually). I also authorise ISA to make all such enquiries (including where appropriate of referees) as it considers necessary to perform its tasks, including to verify the completeness or the accuracy of the information provided by me. I authorise ISA/DEST to use and disclose my information for the purposes of finding me employment, training or education. I also consent to undergo a standard police checks and authorise ISA to obtain information relating to probation and parole as required. I have provided my information to ISA for the explicit purpose of applying for and canvassing job, training or further education opportunities on my behalf.

I acknowledge that the information provided by me to ISA is accurate and not misleading. I acknowledge that I have read and understood the matters set out above and that an ISA representative has provided me the opportunity to discuss any question or concerns that I may have in relation to these matters.

I understand that if I am selected for this programme that I will be on my best behaviour as defined in the ISA/Hostels guidelines and I will help other young people to achieve their goals.