Admission & Enrolment Form

Thank you for applying to CPIT.

We recommend that you read our Admission & Enrolment Guide before starting to complete this form.
The guide is available online at www.cpit.ac.nz/enrol or you can talk to us directly on 0800 24 24 76 for assistance
or to check how your application is progressing.
You must complete every section of this form.
Once we receive your application, we will be in touch either by letter, phone or email.

Section 1 Tips
1 Your name and details

> Please only use a blue or Title Miss Mrs Ms Mr Other (please specify)
black pen
a
> Please print your legal Surname or family name
name in full. If you are not
commonly called by your a
legal name please fill in a Given name(s)
preferred given name
a
Preferred given name
> A verified copy of
your birth certificate
or passport needs to Have you previously been known by another name:
be provided with this
aa
form (see Section 10 for Previous family name(s)
details)
> If you have enrolled at aa
CPIT before you will have Previous given name(s)
a Student ID number and
if you have studied in
NZ you may have an NSI Gender Female Male Date of Birth d d/mm/y yyy
or NZQA number. If not
applicable enter N/A Have you previously been enrolled at CPIT? Yes No

a a
CPIT Student ID? NSI or NZQA No. (if known)

aa
Citizenship (Nationality)

Residency Status New Zealand Citizen New Zealand Permanent Resident

Australian Citizen Australian Permanent Resident Overseas

Madras Street PO Box 540 Christchurch 8140

Tel 0800 24 24 76 Fax 03 940 8642 www.cpit.ac.nz info@cpit.ac.nz
Find us on
 Section 2 Tips
2 Your intended programme of study

Programme name
and specialisation or
> If you dont know your stream (if applicable)
start date please enter
the intended month you
will start your study Programme code
a
Level
a
Study start date d d/mm/yyyy
Will you be studying Full time Part time

Do you expect to complete your programme this year? Yes No

> If you are seeking

During your time at CPIT will you be living in New Zealand or overseas? NZ Overseas
Recognition of Prior
Learning you will need
to complete an RPL Do you intend to apply for Recognition of Prior Learning (RPL)? Yes No
application form available
from our website or the Course Selection
Admissions Team. Some CPIT programmes allow you to make choices between courses you would like to study and/or when they run. If
you wish to make your preferred selection now, please contact us for a timetable.
> Complete table with a
details requested; Course Code Learner Group Code Course Title Start Date
if you dont know which
courses to select, then
leave blank

Section 3 Tips
3 Your eligibility to meet entry requirements

A) Please select one of the following to demonstrate how you will meet the entry requirements:
I have provided evidence (attached) to show how I am meeting entry requirements
> Refer to CPIT brochures
or www.cpit.ac.nz I have provided evidence (attached) which shows I believe I meet the academic, English or other entry
for specific entry requirements with alternative evidence (eg work experience, other study or training)
requirements related to
your chosen programme I am still studying to meet the entry requirements
of study
I need to discuss my entry requirements into the programme (please specify below)
> Please attach:
a) verified copies of any
relevant secondary or
tertiary results to I am seeking special entry consideration (please specify below)
support this application a
b) Additional supporting
documentation such as
CV, referee statements,
portfolio, etc B) English language requirements: Is English your first language? Yes No
* See Section 10 for detail
of evidence required. a
If NO, specify language

and attach verified* copies of any English testing (eg IELTS, TOEFL) you may have
 Section 4 Tips
4 Your contact details

Preferred contact method (tick one) Postal Email Text (Mobile)

Your correct contact
CPIT will communicate with you via this address in relation to preparation for, and support of your study with us.
information helps us keep
you informed of your a a a
application status. Email Mobile Landline

Current/prior to study
Please provide your: Street address a
> Residential home address
before studying at CPIT a
Suburb
> Your residential term
a a
address while studying Town/City Postcode
at CPIT (if different from
above)

During study (if different from above)

> Emergency Contact a
Person
Street address

a
Suburb
a a
Town/City Postcode

Emergency contact
Full name a

a a
Phone Relationship to you

Section 5 Tips
5 Your ethnicity

European/Pakeha/NZ European NZ Mori (please specify Iwi)

> Identify your main
ethnicity as 1. You may Australian Other European British/Irish
choose up to 3 ethnicities
in total (Identify these Chinese Cook Island Mori Dutch
as 2, 3)
Japanese Samoan German

Korean Tongan Greek

Cambodian Fijian Italian

Vietnamese Tokelauan Polish

Indian Niuean South Slav

Sri Lankan Other Pacific people Middle Eastern

Filipino Other Southeast Asian Latin America

Indonesian Other Asian African

Other (please specify) a

 Section 6 Tips
> Please note: educational
institutes are required to
report statistical information
to the Ministry of Education
on an annual basis
Section 7 Tips
This information will
remain confidential. It
enables us to discuss with
you the most appropriate
learning support to meet
your specific individual
needs.
Section 8 Tips
This information will help
us to understand and
communicate more easily
with potential students.
CPIT would like to contact
you with information
about events and
activities.
6 Your educational background
This information regarding your educational background is required by the Ministry of Education.
A) SECONDARY EDUCATION
a
Name of last school attended
What years did you attend this school?
yyyy to
yyyy
What is the highest level of achievement you hold from a secondary school? Please tick one box only
No formal secondary qualification 14 or more credits at any level
NCEA Level 1 or School Certificate NCEA Level 2 or Sixth Form Certificate
University Entrance (minimum requirement NCEA Level 3 or Bursary or Scholarship
to study degree programme in NZ)
Overseas qualification (includes International Baccalaureate and Cambridge Exams)
a
Other (please specify)
Not known
B) TERTIARY EDUCATION
Will this be your first year of tertiary study? Yes No
a
If NO, please enter the name of the tertiary institute you last studied at:
a
If NO, what qualification were you studying toward?
If NO, what year was your first year of tertiary study? yyyy
C) PRIOR ACTIVITY
What was your main activity/occupation in New Zealand on 1 October prior to the date of your programme starting?
Secondary school student Polytechnic/Institute of Technology student
University student Private training establishment student
Wananga student Self employed
Wage or salary worker Unemployed or beneficiary (excluding retired)
a
House person or retired Overseas (please specify)
7 Your learning support
Do you live with the effects of an injury, long-term illness or impairment? Yes No
If YES, please indicate your condition/disability by ticking the boxes that apply to you:
Deaf/Hearing Impairment Blind/Vision Impairment Speech
Mobility Dyslexia Specific learning disorder
a
Medical (please specify)
Other (please specify) a
In an emergency would you require help to leave the building? Yes No
8 Your feedback is appreciated
How did you hear about the programme you are applying for?
Advertising In Person Events
CPIT website School visit CPIT Open Day
Internet search Careers Advisor CPIT information session
Social media eg Facebook, Twitter An industry contact Have a Go Day
TV CPIT staff Careers Expo
Radio Family Industry Expo
Print: newspaper, magazine
Outdoor: billboard, bus back, poster
Other (please specify)
I do not give my permission for CPIT to contact me with promotional information.
 Section 9 Tips
9 Your fee payment
If you are enrolling in a programme of study leading to the award of a qualification, full details of your fees will be
included in the Letter of Offer.
> If CPIT confirms your If you are enrolling in a short course, payment can be made immediately using the credit card payment form, or
enrolment in writing online banking details attached.
you must pay ALL If offered a place, how do you intend to pay your fees? (please tick one)
tuition fees and
student services levies Cheque EFTPOS Cash Direct credit Credit card
as set by CPIT, in full
prior to the start date
of your programme Funded study (Youth Guarantee, tertiary taster, scholarship)
of study. If any fees
are unpaid on the first Student loan if you are paying by student loan please
day of teaching CPIT provide us with your Inland Revenue Department (IRD)
reserves the right to number
cancel your enrolment
Apply directly to StudyLink on 0800 88 99 00 or www.studylink.govt.nz.
in writing.
If your loan application is not approved by StudyLink you are still liable for all fees invoiced to you.
> Even if you do not
participate in the
courses you have I authorise CPIT to direct and accept payment of the relevant tuition fees, student services levy, and
enrolled in you are course costs from my student loan account.
still liable to pay all Signature a
fees to CPIT, unless
CPIT receives your
completed signed Training Incentive Allowance (TIA)
Enrolment Amendment Contact your local Work and Income office. You must complete the enrolment first and submit your CPIT invoice
Form within the to Work and Income for payment. If your TIA application is not approved by WINZ and you wish to continue with
relevant refund period.
your enrolment, you are liable for all fees invoiced to you.

Organisation/Company Paying
Please attach a letter from the organisation/company paying your fees to that effect. If for any reason the
organisation/company does not pay your fees you are still liable and must pay all fees yourself.

a
Organisation/Company Name
a
Authorised Contact Person
a
Postal Address

Telephone Number

Letter or purchase order number attached from company/organisation confirming payment of fees
(as above)

Section 10 Tips
10 Your checklist
Have you completed the following:

>*A verified copy is a Read the Admissions & Enrolment Guide and understood the terms and conditions of your admission and
photocopy of your enrolment (www.cpit.ac.nz/enrol)
original document,
signed as being a true Completed all required sections of this Admissions & Enrolment form
and accurate copy by
one of the positions Read, signed and dated the Acknowledgement and Declaration (Section 11)
listed below.
Justice of the Peace Attached a verified* copy of your birth certificate or passport proving your identity, plus
(see Yellow Pages) permanent residency, visa and change of legal name certificate (eg marriage certificate)
Solicitor
Registrar or Deputy
Attached any additional documentation required to support your application such as
Registrar of the Courts
CPIT Admissions
your academic record, CV, police check, health declaration, references, portfolio requirements, etc
& Enrolments staff
member Attached a copy of your highest academic achievement or equivalent at secondary school
(eg NZQA Record of Learning or other Tertiary Institution Academic Transcript)
The following needs to be
included on the copy to be Completed the fees details, and understood you must pay all fees in full prior to the start
considered a verified copy: of your programme or CPIT reserves the right to cancel your enrolment
the words original
sighted Kept a photocopy of this Admission & Enrolment form for your records
name and signature
of person sighting the
original document
institution/organisation
stamp or handwritten
institution/organisation
name
 Section 11 Tips 11 Your acknowledgement and declaration

I hereby apply for admission and enrolment at CPIT and I understand and agree to the following:
> Please read and then a) as soon as CPIT receives my Admission & Enrolment form and proof of my identity, I have a conditional
sign and date below contract to study at CPIT. I can only withdraw from that contract by CPIT receiving a signed completed CPIT
Enrolment Amendment Form as set out in the Admission & Enrolment Form and Guide.

b) that my admission and enrolment at CPIT is subject to:

i) CPIT granting me direct or, when I do not meet direct admission requirements, CPIT granting me special
admission
ii) CPIT sending me a letter confirming my enrolment
iii) CPIT receiving payment of all fees payable by me on or before the first course start date
iv) I understand that CPIT alone may, by letter to me, end my enrolment if CPIT is not satisfied that I intend
to complete the programme/courses I am enrolled in

c) CPIT reserves the right to cancel any course at any time fees and charges paid will be refunded in full to the
person or organisation which paid originally, or may be transferred with the agreement of the original payee
and used as payment towards another course
d) CPIT reserves the right to alter any aspect of any course at any time. Where days, dates or times are altered,
CPIT undertakes to attempt to contact all enrolled students, either at their stated address or contact number
to inform them of such changes
e) that if I receive a CPIT letter confirming my enrolment, I will (subject to my right to withdraw as set out in this
Admission & Enrolment Form and in the Guide) participate in the qualification/courses I am enrolled in and
use my best efforts to successfully complete the qualification/courses
f) that the information I have given CPIT is true, and complete in all respects
> You can read the
g) that I have read and understand the CPIT Policies Personal Information & Privacy Principles as set out in
Terms & Conditions of
Enrolment at the Admission & Enrolment Guide. This sets out the circumstances under which CPIT may use/disclose my
www.cpit.ac.nz/ personal information.
terms-and-conditions h) that I have read and understand the CPIT Student Rights and Responsibilities as set out in the Admission &
Enrolment Guide.
i) that I have read and understand the terms of my conditional admission and conditional enrolment at CPIT
and, if confirmed, terms of my enrolment as set out in the CPIT Admission & Enrolment Guide and this
Admission & Enrolment Form
j) I acknowledge that any information collected by the Literacy and Numeracy assessment tool may be used by
CPIT to measure and report on CPITs performance
k) that I have read, I understand and I agree to the Acknowledgement and Declaration section of the Admission
& Enrolment Form

Signature Date d d/mm/y yyy

Signature
of parent/guardian Date d d/mm/y yyy
If the applicant is under
18 years of age at the date
they are due to commence study

01473 February 2014

 Credit Card Payment Form
Note: This slip will be destroyed once your enrolment has been
processed.

CPIT Student ID
a

Surname or family name

a

Given name(s)
a

Paying By Credit Card

American Express

Master Card

Visa

Name on Credit Card

Credit Card number

a
Expiry date
a
Amount
a
Course code/s

INTERNET BANKING

On your Admission & Enrolment form you will have indicated if

you are paying your fees by internet banking.

If so, you need to:

go to your online banking site and pay your fees into:
CPIT BNZ Account
02-0800-0911670-003

Make sure you include the following details in the deposit

reference boxes:
Particulars student name
Code invoice number (if known)
Reference CPIT student ID number (if known)

FOR ADMINISTRATION PURPOSES ONLY

Enrolment form completed

Date received a

a
Staff member