Title: uc ciri SCHOLARSHIP program – TERMS and conditions
Author: OMG OMG
Last saved by: s423847
Company: OMG

uc ciri SCHOLARSHIP program – APPLICATION form

U | | | | | | | | | Family Name/Surname: | Given name/s:
Student ID Number | | | |

Date of Birth: | DD | MM | YYYY | | Place of Birth:

Indigenous Status:	❑ I identify as Aboriginal	and/or	❑ Torres Strait Islander
Certificate of Aboriginality Attached?   ❑ Yes – attached                     ❑ No – pending                   ❑ No – I require advice

Telephone: | Mobile:
Email Address:
UC Student Email Address:
Postal Address:

Program of Study to be Undertaken:	❑ Honours      ❑ Graduate Certificate     ❑ Graduate Diploma     ❑ Masters (Coursework)
	❑ Masters (by Research)  	❑ PhD  	❑ Professional Doctorate

Title of Course:
Proof of Enrolment:	❑ Yes – attached                     ❑ No – pending

Name of Degree/s already achieved: 
	❑ Copy attached  	❑ No –Copy pending

Name of University:	Year completed:
Financial Information
1.1 Do you have a disability or long term medical condition which may affect your studies?    ❑ No     ❑ Yes (please provide brief details)
1.2 I am registered with Centrelink:    ❑ No   ❑ Yes, and my Centrelink Reference Number (CRN) is:………………………………………..
1.3 I have a Healthcare Card: 	  ❑ No    ❑ Yes, and my Healthcare Card Number is:……………………………………………

1.5 I receive the following payments from Centrelink:
❑ Rent Assistance 	I usually receive $………………………… per fortnight
❑ Disability or carer payment/pension	I usually receive $.................................... per fortnight
❑ Other Centrelink Payments	I usually receive $.................................... per fortnight

1.6 I live with a partner:    ❑ No    ❑ Yes    (You must declare your partner’s average fortnightly income)  $................................ per fortnight

1.7 I receive financial assistance through other scholarships/busaries:  ❑ No   ❑ Yes 
(You must list the name and amount for all, include those for which you have received approval but have not yet received the funds)
Name of scholarship/bursary:……………………………………………………………………… Amount per fortnight: $.....................

Name of scholarship/bursary:……………………………………………………………………… Amount per fortnight: $……………...

1.8 I work:    ❑ No     ❑  Yes       If yes, please declare your average income per fortnight: $.....................................

1.9 Please add up the total payments you listed for each of the following 
	Item 1.5 (Centrelink)	$	
	Item 1.6 (Partner) 	$	
	Item 1.7 (Scholarships/Bursaries)	$	
	Item 1.8 (Employment)	$	
	Total Fortnightly Income:	$

2.0 I have children that I support:  ❑ No  ❑ Yes           Number of Children:………………

2.1 I provide support to other members of my family:    ❑ No       ❑ Yes          
Total number of people supported by your income, including any children specified in item 2.0:………………

Funding Requested

3.0 I am seeking a total of $......................................... from the UC CIRI Scholarship Program. This purpose of the funding is to ...........................…...
	(Item Description eg. Flights)	$	
	(Item Description eg Accommodation)	$	
	(Item Description eg Meals/Incidentals)	$	
	(Item Description eg Parking)	$	
	(Item Description eg Taxis)	$	
Please add or delete lines as needed. If the amount required is more than $5,000 then please insert a note here stating where you will obtain the remaining funds

Supporting Statements
4.0 Please outline your career and personal goals (maximum of 300 words or 1 page):
4.1 Please outline how the Scholarship will assist in your study at UC and/or career path (maximum of 300 words or 1 page)::
Student Declaration

5.0 CENTRELINK DECLARATION: Please complete if you are receiving Centrelink payments or have a Healthcare Card.
❑ I authorise /  ❑ I do not authorise Centrelink to electronicallly provide a statement of information to the University of Canberra to assist in the assessment of my entitlement to Scholarships and Busaries provided by the University of Canberra. I understand that the information provided by Centrelink may include, where relevant, current or historical details of payments received, dpendents, Centrelink deducaqtion, income assets and confirmamtion of my current address. I understand I will be able to obtain a written copy of the Statements at any time from either the University of Canberra or Centrelink. A brochure is available from Centrelink that provides more details about the Centrelink Confirmation eServices or on Centrelink’s website at www.centrelink.gov.au.

5.1 I have read the University’s statement on privacy and the purposes for which my information will be used, available at www.canberra.edu.au/about-uc/policy-and-legislation/privacy.
I understand that the information contained on this form and in the accompanying documents and statements will be used by the UC CIRI Executive Committee to assess my application under the UC CIRI Scholarship Program.
I agree to be bound by the statutes, poliices, guidelines and rules of the University amended from time to time and agree to pay all fees and charges directly arising from my enrolment. I consent to receiving information electronically and agree to access the correspondence of my University email account on a regular basis and to maintain current mailing address details.

5.3 I have read, understood and agree to the terms and conditions of the UC CIRI Scholarship Program.

5.4 In submitting this application, I declare that the information supplied on this form an din the accompanying documents and statements is complete and correct to the best of my knowledge. If any of the information is founds to be false or mislading, I accept that the University may cancel any scholarship or bursary that might be awarded to  me on the basis of this application and I may be required to repay any monies so obtained.

Signature (or scanned signature): | Date:

UC CIRI Scholarship Program (revised October 2016)