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  Level II Sample Form

Print in CAPITAL or BLOCK or UPPERCASE letters.

Title:

Mr c Mrs [ü] Miss c Ms c Dr c Other………………

Family/Last name/Surname:……………SIU………………………...

Given/First/Christian name:…………….CATHERINE………………

Initials of other given names:…………..E…………………………….

Sex: Male c Female [ü]

Birth date/Date of birth/D.O.B.: Day [06] Month [04] Year [1951]

Home address:……103 SUNBURST CRESCENT………………….

Postcode:….4059………..Phone/Tel.:….(07) 2657 1642…………

Facsimile/Fax: ….(07)…2657 1483………………….

Postal address:…AS ABOVE…………………………………….…………..

Postcode:……………………E-mail:…[email protected].…………..

Are you Australian Aboriginal or Torres Strait Islander (A.T.S.I.)?

Citizenship/Nationality:

Australian c New Zealand c Permanent Resident [ü]

Full-fee student visa c Other temporary resident c

Country of birth:………CHINA………………………………………….

Language spoken at home:……MANDARIN………………………..

Disabilities:…………….N/A……………………………………………..

EDUCATIONAL BACKGROUND:

Years of formal schooling:……11…..Year of completion: [1968]

Tertiary education: Yes [ü] No c

No. of years:……8…………..

Highest level achieved:

Marital status:

Single c Defacto c Married [ü] Separated c Divorced c Widowed c

Dependents:

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