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T I S C: Application For Record of Results
T I S C: Application For Record of Results
APPLICANT DETAILS
FAMILY NAME:
GIVEN NAMES:
FULL NAME AS IT
WILL APPEAR ON
ORIGINAL RECORD:
Please leave blank if same as above. If different, also provide proof of name change.
DATE OF BIRTH:
GENDER (M/F):
POSTAL ADDRESS:
POSTCODE:
TELEPHONE:
EMAIL:
SIGNATURE:
DATE:
DOCUMENT(S) REQUIRED
Tick item(s)
required
$37.00 per copy
Year(s)
of examination
(Date of birth)
METHOD OF PAYMENT
Payment is only accepted in Australian dollars. Forms received without payment will be returned unprocessed.
Mastercard
Visacard
with the amount of $ __________________ being for _____________ result/s @ $37 per copy.
SIGNATURE OF CARDHOLDER:
DATE:
NOTE: Should credit card payment be declined your form will be returned unprocessed. Also should you be using a non-Australian
credit card, confirm with your bank that overseas transactions are acceptable before submission. If not acceptable, a bank draft in
Australian Dollars would be required.
Office use only
Checked ID
CheckedManual
Photocopied
Posted/Collected
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DATE:
REGISTRATION No:
POSTCODE:
DAYTIME TELEPHONE:
Dentist
Doctor
Electorate Officer {State WA only}
Engineer
Teacher
Tribunal officer
Veterinary surgeon
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