Indigenous Commonwealth Scholarships Semester 1, 2016

Transcription

1 Indigenous Commonwealth Scholarships Semester 1, 2016 Contact details Q1 Title: Family name: Given name/s: USQ student number: Daytime telephone number: Mobile: Q2 Mailing Address Number and street: Suburb/town: State: Postcode: Country: Q3 Permanent residential address As above Number and street: Suburb/town: State: Postcode: Country: Personal details Q4 Date of birth (dd/mm/yyyy): Q5 Gender: Female Male Gender X_ Prefer not to disclose Q6 Are you an Australian Citizen?: Q7 Do you identify as an Australian Aboriginal and/or Torres Strait Islander? Refer to Application Checklist on final page for details of documentation required. Q8 Is English your first language? If no, what is your first language? SS/SCH CWITH /102025/017/DEC15/VER2 Page 1 of 8

2 Scholarship for which you are applying I wish to be considered for the following scholarship/s: (you may tick more than one box) Indigenous Access Scholarship (IAS) For those enrolled in Bachelor degrees or the Graduate Diploma of Learning and Teaching only: Indigenous - Commonwealth Education Costs Scholarship (ICECS) Indigenous - Commonwealth Accommodation Scholarship (ICAS) For those enrolled in IHEPP, Tertiary Preparation Program (TPP) only: Indigenous Enabling - Commonwealth Education Costs Scholarship (IECECS) Indigenous Enabling - Commonwealth Accommodation Scholarship (IECAS) Students who already hold a Bachelor's degree are not eligible for the above Scholarships unless enrolled in the Graduate Diploma of Learning and Teaching. Previous Commonwealth Scholarship holders only Q9 Have you previously held a Commonwealth Scholarship (CECS, CAS or Indigenous Access Scholarship) at USQ or another university? Q10 Have you ever had an Indigenous Commonwealth Scholarship cancelled? If yes, specify details of your previous Scholarship and reasons why it was cancelled. Education History Indicate if you were studying during the years in the table below - leave blank for years where you were not studying: Calendar year Grade Town 2015 Name of school/tafe/ University or other education provider Were you able to complete this study in your home town? Yes/No Page 2 of 8

3 Study details Q11 What is your program of study at USQ? Q12 Are you studying full-time this semester? If no, please indicate the reason for part-time study: Disability Medical Significant Carer Responsibilities USQ course offering restraints/prerequisite requirements Employment commitments No specific reason My preferred option Indigenous community responsibilities Other (please specify): _ Q13 At which campus are you studying? Toowoomba Springfield Ipswich External/Online Residential circumstances Q14 Students from regional/remote areas are given priority for these Scholarships. Are you from a regional/remote area? If yes, provide evidence of your current residential address. Refer to Application Checklist on final page for details of documentation required. Q15 Have you relocated to enable you to attend classes at USQ? If yes, what was your home address for each of the last 4 years? 2015: Postcode: 2014: Postcode: 2013: Postcode: 2012: Postcode: Refer to Application Checklist on final page for details of documentation required. Page 3 of 8

4 Personal circumstances Q16 Which one of the following best describes your living situation during the semester? a) Single - living at home and wholly or partially supported financially by family. b) Single - living at home and financially independent. c) Single - living away from home and wholly or partially supported financially by family. d) Single - living away from home and financially independent. e) Partnered - No dependents. f) Partnered - with dependents. No. of dependents: Age of dependents: g) Sole parent/carer No. of dependents: Age of dependents: h) Other, please specify: Q17 Do you have a disability or ongoing medical condition which may affect your studies? If yes, attach a copy of at least one of the following documents: a copy of current Learning Support Plan from USQ Disability Resources a copy of your Disability Support Pension Centrelink statement a copy of a statement or report from a Medical Practitioner. Note: If you have a disability or ongoing medical condition, you are encouraged to make contact with USQ Disability Resources to discuss what support may be available during your studies at USQ. Q18 If you ticked Q16(f) or Q16(g) above, do any of the dependents have a disability or medical condition which may impact on your ability to study? If yes, attach a copy of at least one of the following documents: a copy of current Learning Support Plan from USQ Disability Resources a copy of your Disability Support Pension Centrelink statement a copy of a statement or report from a Medical Practitioner. Financial circumstances All applications must include your bank statements for the most recent 3 months. Applications that do not include 3 months of your most recent bank statements are automatically unsuccessful. Bank statements must clearly identify the name of the account holder. Q19 Are you the holder of a Health Care Card or Pension Concession Card? Attach a copy of your card. Page 4 of 8

5 Q20 Do you receive any Centrelink Income Support Payment? If yes, specify which type. ABStudy Austudy Youth Allowance Newstart Parenting Payment Carer Payment Disability Support Pension Family Assistance Payment Other (please specify) Attach a copy of your Centrelink Statement. If no, have you or will you lodge an application with Centrelink? If yes, on what date did you or will you lodge a Centrelink application? Q21 Are you employed? Q22 If yes to Q21, what is your gross income per year? $ Note: gross income is the figure before tax is deducted. Attach a copy of your Personal ATO Notice of Assessment (most recent year). Q23 If yes to Q21, are you able to continue employment with your current employer whilst studying at USQ? Q24 If living with your parent/s or partner, do they receive any Centrelink Income Support Payment? ABStudy Austudy Youth Allowance Newstart Parenting Payment Carer Payment Disability Support Pension Family Assistance Payment Other (please specify) Attach a copy of their Centrelink Statement. Page 5 of 8

6 Q25 If living with your parent/s or partner, what is their gross income per year? $ Attach a copy of their Personal ATO Notice of Assessment (most recent year). Personal statement Q26 Are there any details which indicate further disadvantage which you would like to elaborate on or have not mentioned that you would like taken into consideration? If yes, attach a separate statement. Statements must be supported by relevant documents. Q27 Will you have ongoing access to a reliable internet connection or account for the duration of your study? If no, please describe your circumstances: Marketing To assist us with marketing, please indicate how you found out about this Scholarship. Declaration You must read and accept all conditions in the following declaration and authority before submitting your application. Your application cannot be considered unless you accept these conditions. By signing this form you also: Declare that, to the best of my knowledge and belief, all the information I have provided is true and correct. Recognise that it is your responsibility to provide all the necessary documentation to support this application as per the Application Checklist. Authorise USQ to verify any information provided by you. Are aware that your application will be considered only for the specific Scholarship/Bursary that you have named at the commencement of this form, and The information you have provided will be shared with staff involved in the selection process. Understand that giving false or misleading information is a serious offence under the Criminal Code Act 1995 (Commonwealth). I agree I disagree Signature: Date: Note: unsigned applications or those without required supporting documentation will not be considered. Page 6 of 8

7 Notice and consents regarding your personal information collected on this Form USQ is collecting the personal information on this Form for university purposes of providing its tertiary education and related ancillary services and the associated functions including managing, administering, assessing applications for, selecting recipients, awarding (including through publication) and reporting on Scholarships or Bursaries at USQ and for these purposes you consent to the transfer of your personal information outside of Australia and if a successful applicant, publication. USQ collects this information in accordance with the Commonwealth Higher Education Funding Act 1988, the Higher Education Support Act 2003, Scholarships Guidelines (Education) 2013, the Education Services for Overseas Students Act 2000 (ESOS Act), ESOS Regulations 2001 and the National Code of Practice for Registration Authorities and Providers of Education and Training to Overseas Students USQ may disclose some or all of this information to the relevant government departments or agencies such as Centrelink or their authorised agents or contracted service providers, who may give it to other government entities, and if relevant, the third party associated with funding the Scholarship or Bursary (and their appointees) and your USQ approved representatives (agents and partners). Other than as set out herein, your personal information will not be disclosed to any other third party without your consent unless required or authorised to do so by law. Your rights to access and amend your personal information are set out in the Information Privacy Act 2009 (Qld) which also places obligations on USQ as to how we handle your personal information. For further information concerning Privacy, please direct any queries to the USQ Privacy Officer. Proof of Aboriginality Australian Aboriginal and/or Torres Strait Islander students must provide their documents of Aboriginality to be considered for an Indigenous Commonwealth Scholarship. Documents may be one of the following: Confirmation of Aboriginality signed by the Board of Committee of an incorporate Aboriginal and/or Torres Strait Islander community organisation. Official letter from an approved representative of the Torres Strait Regional Authority (TSRA). A current Abstudy statement. A Statutory Declaration signed by the student affirming each of the following: o Aboriginal and/or Torres Strait Islander ancestry; and o Identifying as Indigenous; and o Known in a community as being of Indigenous heritage and identifying as such. Proof of Residence Question 14 and 15: If you answered 'yes': Proof of residence for the last 4 years immediately before commencing your course of study. Documentation must show your name, address including postcode and dates. Example of suitable documents: Centrelink letters Drivers licence Electoral Commission notice Rates notice School reports Telephone or electricity bills Page 7 of 8

8 Application Checklist Have you answered all the questions? Have you agreed to the Conditions of the Declaration? Have you attached your most recent 3 months of bank statements? (Compulsory for all applications.) If you answered 'yes' at any of the following questions and this symbol appears you are required to attach the documents indicated. Questions 7, 14, 15, 17, 18, 19, 20, 22, 24, 25 and 26 Have you signed and dated your application? (Compulsory for all applications.) Attachments Provide CERTIFIED COPIES ONLY (certified by a Justice of the Peace or a Commissioner of Declaration) of the documentation submitted. Every single page of every document must be certified. Bank statements and Centrelink statements printed directly from the web do not need to be certified. Do not send originals as documentation will not be returned. Staple your application and documents together. DO NOT USE PAPERCLIPS. Do not attach applications for other scholarships to this application. Application Submission Please mail or deliver your application to Private and Confidential Scholarships Office Student Services G Block University of Southern Queensland West Street Toowoomba QLD 4350 Due date: Friday 11 March 2016 for Semester 1, The Scholarships Office DOES NOT ACCEPT applications via fax or . Want to know more? If you have any questions about your application, please contact: Scholarships.Officer@usq.edu.au University of Southern Queensland is a registered provider of education with the Australian Government CRICOS QLD 00244B NSW 02225M Page 8 of 8