The Salvation ArmyAustralia Southern Territory Catherine Booth College

Eva Burrows Scholarship

Application Form

Information provided in this form will be managed according to the Salvation Army’s Privacy Policy

(see)

(Please expand the size of any space to allow for a full response. If completing manually and additional space is required, indicate in space provided and attach extra sheet/s)

Title
Surname
Given Name / As on travel documents - please provide a certified copy of the documents
Mr Mrs Ms Miss Other
Lieutenant Captain Major
Preferred name
(If other than above)
Residential address
(Include Number, Street, Suburb, State)
Postal address
(If other than above)
Email address
Phone number(s)
Date of birth
Citizenship status / (Please attach certified documentary evidence of Australian permanent resident or citizenship status)
Current occupation
Involvement with The Salvation Army / (Provide details of past and present involvement in any capacity, including officer rank if any)
Previous education
/ (Attach certified copies of results. Include details of highest level achieved)
Comment on any health issues that may impact your capacity to complete the planned studies
Previous professional or leadership development activities / (Include details of how you have supported the development of both yourself and others)
Proposed study or development activity / (Include estimated costs and time commitment)
Describe the knowledge and abilities you hope to gain through the scholarship
How do you expect to use this knowledge and ability?
Explain why this application should be favourably considered
Have you any plans to deal with the issue of any required study leave?
Referees
Provide full details of at least three referees in the table below
Attach from two of these a written reference that sets out the applicants ability to fulfil the scholarship requirements
Referee #1
Name
Position
Contact details / Phone:
Email:
Address:
How does this person know you?
Referee #2
Name
Position
Contact details / Phone:
Email:
Address:
How does this person know you?
Referee #3
Name
Position
Contact details / Phone:
Email:
Address:
How does this person know you?
I declare that all the details in this application are true and correct.
If awarded a Scholarship I will abide by the Scholarship Terms, Conditions and Criteria (see link), and will do my utmost to fulfil the outcomes set out in my Scholarship application.
Name
Signature
Date

The completed form and attachments are to be emailed to
by 15 September 2017

Application form - Australia #1 v0.45 June 2017Page 1 of 3