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International Diploma Application Form

Before applying for admission to the next MDT Diploma Programme, please ensure you have thoroughly read and understood the following:

Title

First Name

Last Name

Credentials

Date of Birth

Address

Phone (Work)

Phone (Mobile)

Profession

Nationality

Please list any medical conditions or disabilities that may affect your participation in the Diploma MDT Programme:

Clinical Training sites are currently available in Australia, Belgium, Canada, Denmark, France, Germany, Netherlands, Sweden and the USA. However, the availability can vary, hence there is no guarantee that you will be able to complete your clinical at a

Qualifications (List relevant Degrees, Diplomas & Certificates)

Qualification

Granting Institution

Year

Clinical Experience commencing with most recent:

Employer

Location

Dates: From -To

Details of your attendance of the McKenzie Institute Advanced Extremities Course and Credentialling Examination:

Course Name

Location

Instructor/Examiner

Date

Please expand on your reasons for wanting to complete the MDT Diploma Programme

I hereby consent for my name and email address to be provided to other candidates who are also enrolled in The McKenzie Institute International Diploma Programme

Please attach copies of ALL of the following documents (max file size 1.5GB):

Academic Qualification eg Diploma/Degree

Professional Body registration

Photo page copy of passport/identification document

Marriage certificate (if there has been a change of name)

TOEFL, IELTS or Pearson Test Score Report (only applies to those for whom English is not their first language)

Full Curriculum Vitae

Credentialling Exam certificate

Advanced Extremities certificate

Professional reference 1

Professional reference 2