2017 Higher Education Scholarship Application

Applications must be received by 4.30pm on Friday 10 March 2017

Please read the 2017 Higher Education Scholarship eligibility criteria and terms before completing this form https://nt.gov.au/learning

2017 Higher Education Scholarship Application /
Personal details
Family name / Date of birth
Given name(s) / Male / Female
Residential address
State / Post code
Postal address
State / Post code
Home phone / Mobile phone
Email address / Phone contact during term
Nominated contact person (for example, parent, guardian, relative) to receive requests and provide information regarding this scholarship if required
Name / Relationship
Residential address
State / Post code
Home phone / Work phone
Email address / Mobile phone
Length of residency in the Northern Territory / years
Are you an Australian Citizen? (if ‘No’, proof of permanent residency) / Yes No
Are you of Aboriginal or Torres Strait Islander descent? / Yes No
Are you from a non-English speaking background? / Yes No
If ‘Yes’, what is your first language spoken at home?
Do you have a disability? If ‘Yes’, please briefly describe / Yes No
Education information - a copy of your results must be attached
What high school did you complete Year 12?
What year did you complete Year 12? / 2015 2016
Northern Territory Board of Studies Higher Education Entrance Information - Australian Tertiary Admission Rank (ATAR) score or
International Baccalaureate
Other financial assistance
Have you applied for any other scholarships or grants, or will you receive study assistance from any other source? If ‘Yes’, please advise details. / Yes No
Source / details
Will the other assistance be paid directly to you or to the university for course fees or accommodation costs.
Amount ($ per annum)
When will you be notified that your application for other assistance has been successful or not?
University enrolment - a copy of the course enrolment must be attached
Name of university
Address
Course name
Course major
Course code / Length of full-time course
Application check list - your application will not be assessed unless the following information is attached (please do not send original documents)
Proof that you live in the Northern Territory (for example, copy of driver’s licence or a bank statement with residential address).
Proof of Australian citizenship or permanent residency (birth certificate, passport or immigration document).
Proof that you have completed the NTCET or equivalent.
Proof of 2015 or 2016 ATAR or IB.
Confirmation of university enrolment which shows the units you are enrolled in for semester 1, 2017, your name and the name of the university.
Personal Statement (page 3 of application)
Outline how the scholarship will assist you, what career path you wish to take and if you intend to work in the NT after graduation.
Personal statement
Name
Outline how the scholarship will assist you, what career path you wish to take and if you intend to work in the Northern Territory after graduation.
If studying interstate, why studies cannot be undertaken in the Northern Territory (evidence of the core differences in the courses offered and outcome must also be attached).
Declaration
I completed the NTCET or IB in the NT in 2015 or 2016.
I have read and understand the Northern Territory Government eligibility criteria and terms of the 2017 Higher Education Scholarship.
I certify that I meet the eligibility criteria and my application is within the terms and conditions and I intend to continue to meet the terms and conditions if granted a scholarship. I understand that a breach of the terms and conditions could lead to withdrawal of the scholarship and in certain circumstances recovery of monies paid under the scholarship.
I declare that the information contained in this application and attachments is, to the best of my knowledge, true and correct.
Signature / Date

For further information and assistance with completion of this form, telephone the Scholarships Administrator on (08) 8935 7706.

If the Scholarships Administrator requests further information to support your application a date will be advised for the information to be received. If the information is not received by the set date the application will be deemed ineligible.

Email your application and supporting documents to

Applications close at 4.30 pm on Friday 10 March 2017.
Late applications will not be accepted.

The NT Government is collecting this information for the administration of the Northern Territory Government Scholarships. Only authorised officers have access to this information. Your personal information will not be disclosed to any other third party without your consent, unless authorised or required by law, in accordance with the Information Privacy Principles.

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