Swinburne University of Technology
in conjunction with the
Executive Counselling & Training Academy

APPLICATION FORM FOR ADMISSION TO GRADUATE DIPLOMA IN CLINICAL SUPERVISION AWARDED BY SWINBURNE UNIVERSITY OF TECHNOLOGY

Graduate Diploma in Clinical Supervision

Duration: 1 year

Course Commences: 1 July 2017 Closing Date: 1 June 2017

Before submitting this application, please ensure that you have prepared all items under "Checklist" (point 8).

* Required field

1. PERSONAL DETAILS
Name (as in NRIC / Passport) *
NRIC / Passport Number *
Country of Birth *
Citizenship *
Date of Birth *
Marital Status *    
Mailing Address *
Phone Numbers
Mobile *
Home
Email Address *
Religion *
Language(s) Spoken *

2. EDUCATION DETAILS

Post-Secondary / Tertiary Studies *

List all tertiary or post-secondary studies completed. (Include current year studies.)

Name of Institution Name of Qualification
(Degree or Diploma)
Years Attended Completed
Yes No
Yes No
Yes No
Yes No
Yes No

Please indicate whether your highest qualification was awarded by:

University Degree (Overseas - Studied on Campus)
Diploma (Overseas - Studied on Campus)
University Degree (Through Distance Learning)
Diploma (Through Distance Learning)
University Degree awarded by Local University
University Degree awarded by Local Private Education Institution
Diploma awarded by Local Polytechnic
Diploma awarded by Local Private Education Institution

3. ADDITIONAL INFORMATION
Other qualifications or certificate of attainment or competencies * Yes No
If Yes, please give details
The year you completed the qualification or certification
Are you sponsored by an organisation? * Yes No
If your response is "Yes", please provide name of organisation

4. EMPLOYMENT & WORK EXPERIENCE

Details of relevant employment or work experience

Organisation Position or Title Dates Full
Time
Part
Time
From To
Present Occupation
Title
Since
Number of Years
Brief description of current roles, duties and responsibilities

5. CLINICAL PORTRAIT
Clinical Experience Hours Dates
From To
Number of clinical supervision hours that you have received post graduation
Individual
Group
Number of face-to-face counselling hours post graduation (minimum 300 hours)
Number of supervision hours that you have given to supervisees post graduation

6. ANTECEDENT
Have you ever suffered or are you suffering from any medical condition, illness, disease, mental illness or physical impairment? Yes No
Do you have any history of psychiatric disorder? Yes No
Are you currently taking any prescription drugs or medication? Yes No
Have you ever been convicted in a court of law in Singapore or in any country? Yes No
Have you ever been charged with any offence in a court of law in Singapore or in any country for which the outcome is pending? Yes No
If any of the answers is "YES", please furnish details:

7. DECLARATION
(a) I understand that all the information provided will be used in the admission process. The data will also become a part of my student record and may be used for all purposes relating to my studies in accordance with the procedures of the Swinburne University of Technology and the Executive Counselling & Training Academy.
(b) I declare that the information given to support this application form is accurate and complete. I am aware that Swinburne University of Technology reserves the right to cancel my application at any time if the information given in this application is found to be untrue. If accepted as a student, I will comply with all conditions, rules and regulations of the University and its representative.
(c) This form collects personal data relevant to the processing of course application and other related administrative matters, including correspondence with the applicant. Data collected will be treated as confidential and used by the academy only for official purposes. If accepted into the relevant course(s), the student may from time to time participate in events organised by the academy where his/her image may be captured in photographs or video-recordings. By submitting this form, the applicant consents to the use of the data for the purposes indicated, and to photographs or videos containing his/her image being used on the school’s website or publications for publicity purposes.

8. CHECKLIST

Applicants must complete the application form. Applicants are required to bring the following documents to ECTA for verification.

  1. One copy of your GCE "O" Level Certificate and any other degrees, diplomas, certificates and official transcripts
    (* Please bring the original documents for the interview)
  2. One copy of your resume
  3. One copy of your Identity Card (both sides)
  4. One recent passport-sized photograph
  5. Passport
  6. A non-refundable Application fee of $160.50 (GST inclusive) (Crossed cheque should be made payable to ECTA)

The completed application package should be mailed to:

Clinical Director
Executive Counselling and Training Academy Pte Ltd
210 Middle Road
#07-02 Singapore Pools Building
Singapore 188994

7. Verification Code *
Enter the verification code:




Executive Counselling & Training Academy
CPE Registration Number: 200209120M
(Period: 20 June 2014 to 19 June 2018)