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Prime Minister’s Pacific Youth Awards Application Form 2016

How your information will be used
I understand that:

  1. The Ministry for Pacific Peoples (The Ministry) is collecting the personal information on this form from me for the purposes of the Prime Minister's Pacific Youth Awards.
  2. My personal information will provided to the Ministry for the purposes of processing my application and for Awards promotional purposes in some cases and I authorise my personal information to be provided to them.
  3. The Ministry is collecting the information and the address is: Ground Floor, Whirinaki House, 7 Springs Road, East Tamaki. The Ministry can be contacted by email at:
    The Ministry is or will be holding the information and the address is Ground Floor, Whirinaki House, 7 Springs Road, East Tamaki. The Ministry can be contacted by email at:
  4. My personal information is being provided voluntarily. If all the information requested is not provided, there are no consequences except where it may affect eligibility for entering the Awards. I am entitled to have access to and to request correction of the personal information held by The Ministry.

Tell us about yourself

Name
Address
Date of birth / Gender / M ☐ / F☐
Phone Details / Home / Mobile
Email
Which ethnic group(s) do you belong to?
(Tick all that apply to you) / Which country were you born in?
Cook Island Maori / ☐ / Cook Island / ☐ /
Fijian / ☐ / Fiji / ☐ /
Maori / ☐ / New Zealand / ☐ /
New Zealand European / ☐ / Niue / ☐ /
Niuean / ☐ / Samoa / ☐ /
Samoan / ☐ / Tokelau / ☐ /
Tokelauan / ☐ / Tonga / ☐ /
Tongan / ☐ / Other (please specify)
Other Pacific Peoples (please specify)
If you were not born in New Zealand, what year did you arrive?
If you were not born in New Zealand, please indicate if you are: / New Zealand Citizen / ☐ /
Permanent Resident / ☐ /
Neither / ☐ /
Have you had a criminal conviction in the last five years? / Yes ☐ / No☐
If you answered ‘yes’, please describe what was the conviction?
How did you hear about the awards?
☐Friend / ☐Poster
☐Relative / ☐Postcard
☐Teacher / ☐Church
☐School / ☐Facebook
☐MPIA staff member / ☐Radio (please specify)
☐News story / ☐Website (please specify)
☐Poster / ☐Other (please specify)

Which award are you applying for?

☐Air NZ Leadership & Inspiration Award
☐Auckland Council Community Star Award
☐AkoAotearoa STEM (Science, Technology, Engineering & Mathematics) Award
☐BNZ Commercial & Corporate Award
☐Creative NZ Arts & Creativity Award
☐Deloitte Business & Enterprise Award
☐NZ Institute of Sport (NZIS) Sports & Fitness Award

Why do you think you deserve this Award?

Describe how you meet the criteria and give examples of what you have achieved under the category you are applying for

Describe any obstacles oror adversity you have overcome to achieve what you have.

In no more than 250 words describe your future aspirations and outline how you think the award you are applying for will/can assist you in reaching these

In no more than 250 words outline what involvement you have within the Pacific community or what you might have in the future?

Referees

Please provide at least two written references to illustrate your ability to meet the criteria of the award you are applying for, your potential to advancing positive outcomes in the Pacific community and why you deserve the award.

Please note that your application cannot be considered unless you have two references.