Revans University - The University of Action Learning
 Program/Degree Information   
Please note that fields marked with * are mandatory
Course / Action Learning Set Name: Course / Action Learning Set Number:
* Desired Program/Degree:

Personal Information 
* Title (Mr/Mrs/Miss...):
* First Name:
* Family/Last Name:
* Known/Preferred Name (William - Bill):
* Preferred Name on Certificate:
  Date of Birth (DD/MM/YYYY):
* Gender:
* Nationality:
* Preferred Correspondence:
  Would you like to receive the University's newsletter:

 Personal Address 
* Address:
* Town/City:
* County/State/Province:
* Postal/Zip Code:
* Country:
* Telephone:
* Email Address:

 Job Information 
* Current Job Title:
* Name of Organization
* Organization Address
* Organization Town/City
* Organization County/State
* Organization Country
* Postal/Zip code
* Telephone Number
Fax Number
* Email Address

 Aptitude Tests 
What aptitude tests have you taken and what were the results? (please give details)
What are your highest qualifications or attainments in the English language:
What are your qualifications or attainments in Statistics and Computing:

 Degrees, diplomas or professional qualifications now held 
* Highest Qualification * Awarded By (Institute) Designatory post-nominal initials * Dates from/to (DD/MM/YYYY)
Other Qualification Awarded By (Institute) Designatory post-nominal initials Dates from/to (DD/MM/YYYY)

 Work experience (describe present position first
* Please give date, Employer, Job title, Responsibilities, plus any other experience of responsibility and achievement.

Give the names and addresses of two references who can comment on your experience and abilities, normally one of whom should be your current employer.
Reference 1
Telephone no.
Email Address
(if available):
Reference 2
Telephone no.
Email Address
(if available):

Revans University request that all Associates complete the following questions
for internal record-keeping, management information purposes, and for the IRS returns.


Disability / Special Needs: (impairment of sight/hearing/mobility)
The Disability field records the type of disability that a Associate has, on the basis of the Associate's own self-assessment, for monitoring levels and trends in participation by particular groups of people.

(please select one)
This field identifies the 'ethnic origin' of Associates.


Source of Tuition Fees:
The purpose of this field is to indicate the major source of tuition fees for the Associate where this is known, to observe the numbers of 'self-financing' Associates for policy matters.

  1. Fees in full are due six weeks before commencement of the program.
  2. Graduation and Certification Fee due upon completion and prior to Graduation is $US 750
  3. Fees for Graduate action learning studies inclusive of Internet courseware and resources (per Associate) are as set out in the published Catalog.

Refund of Fees

Associates who cancel within the first 5 days after application and payment is received are entitled to a full refund of all fees paid. Once an Associate has enrolled on any program, but prior to commencement, the University may retain a maximum of $US 150. Up to and including the completion of Start Up and 25 per cent of the tutorial sessions, 25 per cent of the fees less $US 150 is retainable. After completing more than 25 per cent and up to and including 50 per cent of tutorial sessions, 50 per cent of the fees less $US 150 is retainable. Once an Associate completes more than half of the tutorial sessions the full tuition fees are retainable.

 Declaration of Understanding 

The University undertakes to provide tutors, examiners and inspectors for the duration of your action learning program as set out in the Conspectus.

I have read and understood the above mentioned items and note my acceptance by ticking the boxes below:

(All Faculty Members are prohibited under Article 25 from disclosing any
confidential information which they may receive as a result of the conduct of their duties.)

If you cannot confirm any of the above, email your questions or requests to

The University's Charter for Management Action Learning state:

Provided also that Revans University and IMCA shall in no manner whatsoever discriminate in the pursuit of its objects against any person on the grounds of their political opinions, religion, race, color or sex, rather it should seek deliberately to ensure equal opportunities for all in postgraduation management and take affirmative actions to enable such equality of opportunity to occur and flourish.

When complete, please hit "Submit Application" below. When your posting has been confirmed, press the Back button on your browser and make sure you complete the Corporate Sponsorship Agreement if appropriate.

PLEASE NOTE: It is your responsibility to notify Revans University of any name change prior to your Graduation.