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University of Wollongong - Graduate School of Medicine
ADMISSIONS PORTFOLIO 2010 for 2011
GSM-ADM-2010-2011
1
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
2
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
3
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
4
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
5
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
Position titleWeek Month Year Total
Per
PerWeek Month Year Total
Position title
Position title
Position title
Week Month Year TotalPer
Week Month Year TotalPer
Week Month Year TotalPer
Position title
UNIVERSITY OF WOLLONGONG Graduate School of Medicine
NAME: GAMSAT ID:
Page 1 of 8
First Name
Address
City State Postcode
Country
GAMSAT ID
Phone No.
Date
UNIVERSITY OF WOLLONGONG Graduate School of Medicine
LEADERSHIP
Preferred First Name
Submit before 4:00 PM AEST Friday, 04th June 2010 to email address: [email protected] PORTFOLIO 2010 for 2011 Domestic & International Applicants
Last Name
University of Wollongong - Graduate School of Medicine
ADMISSIONS PORTFOLIO 2010 for 2011
GSM-ADM-2010-2011
1
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
2
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
3
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
4
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
5
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
Position titleWeek Month Year Total
Per
PerWeek Month Year Total
Position title
Position title
Position title
Week Month Year TotalPer
Week Month Year TotalPer
Week Month Year TotalPer
Position title
UNIVERSITY OF WOLLONGONG Graduate School of Medicine
NAME: GAMSAT ID:
Page 2 of 8
CAPACITY TO WORK WITH OTHERS
University of Wollongong - Graduate School of Medicine
ADMISSIONS PORTFOLIO 2010 for 2011
GSM-ADM-2010-2011
1
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
2
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
3
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
4
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
5
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
Position titleWeek Month Year Total
Per
PerWeek Month Year Total
Position title
Position title
Position title
Week Month Year TotalPer
Week Month Year TotalPer
Week Month Year TotalPer
Position title
UNIVERSITY OF WOLLONGONG Graduate School of Medicine
NAME: GAMSAT ID:
Page 3 of 8
SERVICE ETHIC
University of Wollongong - Graduate School of Medicine
ADMISSIONS PORTFOLIO 2010 for 2011
GSM-ADM-2010-2011
1
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
2
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
3
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
4
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
5
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
Position titleWeek Month Year Total
Per
PerWeek Month Year Total
Position title
Position title
Position title
Week Month Year TotalPer
Week Month Year TotalPer
Week Month Year TotalPer
Position title
UNIVERSITY OF WOLLONGONG Graduate School of Medicine
NAME: GAMSAT ID:
Page 4 of 8
DIVERSITY OF EXPERIENCE
University of Wollongong - Graduate School of Medicine
ADMISSIONS PORTFOLIO 2010 for 2011
GSM-ADM-2010-2011
1
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
2
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
3
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
4
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
5
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
Position titleWeek Month Year Total
Per
PerWeek Month Year Total
Position title
Position title
Position title
Week Month Year TotalPer
Week Month Year TotalPer
Week Month Year TotalPer
Position title
UNIVERSITY OF WOLLONGONG Graduate School of Medicine
NAME: GAMSAT ID:
Page 5 of 8
HIGH LEVEL OF PERFORMANCE IN AN AREA OF HUMAN ENDEAVOUR
University of Wollongong - Graduate School of Medicine
ADMISSIONS PORTFOLIO 2010 for 2011
GSM-ADM-2010-2011
1
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
2
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
3
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
4
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
5
ActivitiesApprox
hours
Full Name
Phone No.
Postcode
Start date
Name & address of organisation
Position
End date
Who can we contact to
verify?
Position titleWeek Month Year Total
Per
PerWeek Month Year Total
Position title
Position title
Position title
Week Month Year TotalPer
Week Month Year TotalPer
Week Month Year TotalPer
Position title
UNIVERSITY OF WOLLONGONG Graduate School of Medicine
NAME: GAMSAT ID:
Page 6 of 8
ACADEMIC EXPERIENCE
The UOW GSM is committed to producing medical graduates with a focus on regional, rural and remote communities, giving preference to students who can demonstrate ties to such locations. Please check the Admissions Portfolio guidelines and use the following website to assist in completing this form: http://www.doctorconnect.gov.au/internet/otd/Publishing.nsf/Content/locator
UNIVERSITY OF WOLLONGONG Graduate School of Medicine
Page 7 of 8GSM-ADM-2010-2011
University of Wollongong - Graduate School of Medicine
ADMISSIONS RURAL RESIDENCY & SCHOOLING FORM
NAME: GAMSAT ID:
Question 1: Did you complete the majority of your primary school eduation in a regional / rural area in Australia? (As defined by the Australian Standard Geographical Classification - Remoteness Area ASGC-RA 2 to 5)
Dates attended
School name
School phone School postcode
to ASGC-RA code RA-2 RA-3 RA-4 RA-5
Question 2: Did you complete the majority of your secondary school eduation in a regional / rural area in Australia? (As defined by the Australian Standard Geographical Classification - Remoteness Area ASGC-RA 2 to 5)
School postcode
to
Question 3: Did you complete the majority of your tertiary eduation in a regional / rural area in Australia? (As defined by the Australian Standard Geographical Classification - Remoteness Area ASGC-RA 2 to 5)
University postcode
No, I did not complete the majority of primary school in an ASGC-RA 2-5 area. Proceed to Question 2
Yes, I did complete the majority of primary school in an ASGC-RA 2-5 area. Complete details below
No, I did not complete the majority of secondary school in an ASGC-RA 2-5 area. Proceed to Question 3
Yes, I did complete the majority of secondary school in an ASGC-RA 2-5 area. Complete details below
No, I did not complete the majority of tertiary education in an ASGC-RA 2-5 area. Proceed to Question 4
Yes, I did complete the majority of tertiary education in an ASGC-RA 2-5 area. Complete details below
School phone
Dates attended
School name
University phone
Dates attended
University name
ASGC-RA code RA-2 RA-3 RA-4 RA-5
to ASGC-RA code RA-2 RA-3 RA-4 RA-5
The UOW GSM is committed to producing medical graduates with a focus on regional, rural and remote communities, giving preference to students who can demonstrate ties to such locations. Please check the Admissions Portfolio guidelines and use the following website to assist in completing this form: http://www.doctorconnect.gov.au/internet/otd/Publishing.nsf/Content/locator
UNIVERSITY OF WOLLONGONG Graduate School of Medicine
Page 8 of 8GSM-ADM-2010-2011
University of Wollongong - Graduate School of Medicine
ADMISSIONS RURAL RESIDENCY & SCHOOLING FORM
NAME: GAMSAT ID:
Question 4: Did you reside in a regional / rural area of Australia for at least 5 years (consecutive or cumulative) from commencement of primary school, that is commencement of school at about the age of 5 years? (A regional or rural area as defined by the Australian Standard Geographical Classification - Remoteness Area ASGC-RA 2 to 5)
Dates resided
Main location
to
to
to
to
to
If you answered "yes" to any of the above questions you may be required to provide additional supporting evidence .
The GSM reserves the right to check your details with any schools listed. Any incomplete or incorrect forms will not be considered.
Any applicants found to be making deliberately false statements will be removed from the application process.
ASGC-RA code RA-2 RA-3 RA-4 RA-5
ASGC-RA code RA-2 RA-3 RA-4 RA-5
ASGC-RA code RA-2 RA-3 RA-4 RA-5
ASGC-RA code RA-2 RA-3 RA-4 RA-5
ASGC-RA code RA-2 RA-3 RA-4 RA-5
No, I have not resided in an ASGC-RA 2-5 area for more than 5 years. Proceed to declaration at end of form.
Yes, I have resided in an ASGC-RA 2-5 area for more than 5 years. Complete details below
Yes, I understand the above conditions and declare the information I have provided to be true and correct
Other location
Dates resided
Other location
Dates resided
Other location
Dates resided
Other location
Dates resided