DIPLOMA IN MUSIC PERFORMANCE 2015 APPLICATION FORM & TAX INVOICE Candidate information

No stapled cheques please
DIPLOMA IN MUSIC PERFORMANCE
(DipABRSM & LRSM) 2015
APPLICATION FORM & TAX INVOICE
Candidate information
Candidate
number
(if applicable)
Title
Family name
First name
Qualifications
Male
Female
Address
Home telephone (
)
Suburb
Work telephone (
)
City/Town
Fax (
)
Post code
Mobile telephone (
)
Email
Date of birth
Identification
Passport
Driving licence. A photocopy must be enclosed with this form
Alternative contact person
If the candidate is under 16 years of age, or if someone other than the candidate should be contacted regarding this application, please provide the
details below.
Name _____________________________________________________ Email _________________________________ Phone ___________________
Examination options
DipABRSM
LRSM
Please check that you have fulfilled the necessary prerequisites – see page 20 of the syllabus. A photocopy of the necessary documentation must be
enclosed with this form.
If you wish to sit an FRSM exam, or if you plan to take a specialist option (e.g. chamber music), please contact the ABRSM office to request the
appropriate application form.
Instrument
______________________________________________
This is the first time I have entered this exam
I have entered this exam before and would like to retake the complete exam
I have entered this exam before and would like to retake only part(s) of the exam –
Exam session:
Performance
Viva Voce and Programme Notes
Quick Study
Diploma 1 Closing date: 13 March. Exams: 11 May to 3 July
Diploma 2 Closing date: 7 August. Exams: 19 October to 4 December
Town/city: __________________________________________________
Specific needs (e.g. visual or hearing impairment, dyslexia, or other considerations) ________________________________________________________
If you would prefer your exam to be scheduled early or late in the session, or have other comments regarding your availability, please write the details
here:
_____________________________________________________________________________________________________________________________
We cannot guarantee to meet any date requests.
Payment
Complete exam: DipABRSM – $500
LRSM – $1510
Partial retake:
Please contact the ABRSM office to request the retake fee
applicable to your exam and complete the amount below.
Payment Options (tick all that apply)
Cheque Enclose cheque(s) made out to ABRSM with this form
Online Date paid______________
Transfer fees to ANZ account
06 0115 0109313 02
$ _____________________
• Particulars – Diploma
• Code – Exam town or city
• Reference – Candidate name
and include the information below:
GST No. 30-296-524
Declaration
I have read and undertake to abide by the regulations in the current Diploma Syllabus.
Candidate signature: _________________________________________ Date: _____________________
If the candidate is under 16 years of age, this declaration must also be signed by a parent or guardian.
Parent/guardian signature: ____________________________________ Date: _____________________
Check list
All details in this form are complete and correct
A copy of the identification document (e.g. passport or drivers licence) is enclosed
A copy of the prerequisite documentation is enclosed
A cheque payment is enclosed or the fee has been paid online
Send your form and other documents to either your local representative or to the ABRSM office
(details below) to reach us before the closing date for your exam session.
Once your application has been received, you may be asked to provide further information. You will
then receive your appointment notice about three weeks after the closing date.
After your exam, the examiner’s report and a recording of your exam will be sent to London for
moderation. The results are then sent back to New Zealand. This process will take around eight
weeks.
PO Box 34433, Birkenhead, Auckland 0746
129A Onewa Road, Northcote, Auckland
telephone (09) 480 1200 ■ freephone 0800 MUSEXAM (0800 687 392) ■ fax (09) 480 1201
text 02 ABRSM 200 ■ email office@abrsm.org.nz ■ web www.abrsm.org/nz
Candidate declaration form
Do not send this page with your application. Complete the details below and give it to the
examiner(s) at the start of your exam.
Declaration – I confirm that I have read the regulations in the current Diploma Syllabus and that:
• The attached Programme Notes are genuinely my work and I am the sole author
• They have not previously been submitted to ABRSM or to any other institution or agency for another
academic award
• The sources used and quoted are properly acknowledged and listed
• I have read the section on plagiarism below and understand that I will be penalised or disqualified if
a charge of plagiarism is upheld
Signature: _______________________________________ Date: _____________________
ABRSM defines plagiarism as an attempt to pass off as one’s own the work of others.
Thus copying from a printed or unprinted source without acknowledging it, or constructing a précis of someone else’s writing
without citing indebtedness to that writer, constitutes plagiarism.
In preparing the Programme Notes candidates are encouraged and expected to read widely to demonstrate the breadth of
their reading and, where appropriate, to quote the work of others. However, such quotations and references must be properly
and fully attributed in accordance with the advice provided by ABRSM. Candidates who ignore this advice run the risk of being
accused of plagiarism.
The Chief Examiner will refer any suspected cases of plagiarism to the Diploma Board.
The Diploma Board may disqualify a candidate if the charge of plagiarism is upheld. Candidates will have a right of appeal and
representation if such charges are made.
PO Box 34433, Birkenhead, Auckland 0746
129A Onewa Road, Northcote, Auckland
telephone (09) 480 1200 ■ freephone 0800 MUSEXAM (0800 687 392) ■ fax (09) 480 1201
text 02 ABRSM 200 ■ email office@abrsm.org.nz ■ web www.abrsm.org/nz