Application Form

Please note that fields marked with * are mandatory

Program/Degree Information

Course / Action Learning Set Name:
Desired Program/Degree:
Commencing (MM/YYYY):

Personal Information

* Title (Mr/Mrs/Miss...):
* First Name:
* Family Name:
* Preferred Name: (e.g. Bill rather than William)
* Preferred Name on Certificate
* Gender	FemaleMale
* Nationality:
* Preferred Correspondence	PersonalBusiness
Date of Birth (dd/mm/yy):

Personal Address

* Home Address:


* Town/City:
* County/State:
* Postcode:
* Country:
* Telephone number:
Mobile Phone number:
Fax number:
* Email Address:

Career information

* Current Job Title:
* Name of Organization:
* Address:


* Town/City:
* County/State:
* Postcode:
* Country:
* Telephone number:
Mobile Phone number:
Fax number:
* Email Address:

Degrees, diplomas or professional qualifications now held

* Highest Qualification	* Awarded By (Institute)	Post-nominal initials	* Dates from/to (DD/MM/YYYY)

Other Qualification(s)	Awarded By (Institute)	Post-nominal initials	Dates from/to (DD/MM/YYYY)

Work experience

* Describing your present position first please give dates, Employer, Job title, Responsibilities, plus any other experience of responsibility and achievement

References

Give the names and addresses of two references who can comment on your experience and abilities, normally one of whom should be your current employer.

Reference 1
Name:
Position:
Address:


Postcode:
Telephone no.
email Address (if available):

Reference 2
Name:
Position:
Address:


Postcode:
Telephone no.
email Address (if available):

Revans University request that all Associates complete the following questions for internal record-keeping, management information purposes, and for the IRS returns.
Disability / Special Needs: (impairment of sight/hearing/mobility) The Disability field records the type of disability that a Associate has, on the basis of the Associate's own self-assessment, for monitoring levels and trends in participation by particular groups of people.	Ethnicity: (please select one) This field identifies the 'ethnic origin' of Associates.

Source of Tuition Fees: The purpose of this field is to indicate the major source of tuition fees for the Associate where this is known, to observe the numbers of 'self-financing' Associates for policy matters.
Fees paid by sponsor Fees paid by individual Fees paid in part by sponsor and part by individual Refund of Fees Associates who cancel within the first 5 days after application and payment is received are entitled to a full refund of all fees paid. Once an Associate has enrolled on any program, but prior to commencement, the University may retain a maximum of $US 150. Up to and including the completion of Start Up and 25 per cent of the tutorial sessions, 25 per cent of the fees less $US 150 is retainable. After completing more than 25 per cent and up to and including 50 per cent of tutorial sessions, 50 per cent of the fees less $US 150 is retainable. Once an Associate completes more than half of the tutorial sessions the full tuition fees are retainable.

Declaration of Understanding

The University undertakes to provide tutors, examiners and inspectors for the duration of your action learning program as set out in the IMCA Conspectus.

I have read and understood the above mentioned items and note my acceptance by ticking the boxes below:

(1) I understand that Revans University undertakes to provide tutors, examiners and inspectors for the duration of my action learning programme

(2) I understand the requirements of the programme I have applied for and will make the necessary commitment in terms of workload and application

(3) I will hold in confidence any personal or private business information given to me by colleagues during my action learning studies.

(4) I acknowledge that the fees are payable per module and are payable in advance by bank direct debit- or paid one semester in advance, except where alternative arrangements have been agreed. I also acknowledge that there is a Graduation and Certification fee as detailed above payable upon successful completion of the programme, and prior to Graduation

(5) I have read and understood the Refund Policies

(All Faculty Members are prohibited under Article 25 from disclosing any
confidential information which they may receive as a result of the conduct of their duties.)

If you cannot confirm any of the above, email your questions or requests to revans-university@vanuatu.com.vu

The University's Charter for Management Action Learning state:

Provided also that Revans University and IMCA shall in no manner whatsoever discriminate in the pursuit of its objects against any person on the grounds of their political opinions, religion, race, color or sex, rather it should seek deliberately to ensure equal opportunities for all in postgraduation management and take affirmative actions to enable such equality of opportunity to occur and flourish.

PLEASE NOTE: It is your responsibility to notify Revans University of any name change prior to your Graduation.