Rotoma No.1 Incorporation
Education Scholarship
2015
Application Form
NOTES TO APPLICANTS
1. Only shareholders, or their children, grandchildren, or great grandchildren (or
beneficiaries under a Whanau Trust which is a shareholder) are eligible for an
education grant.
2. Applicants MUST be Full Time students at an accredited tertiary education
institution.
3. A bank deposit slip must be attached.
4. Confirmation of Full Time Enrolment must be accompanied by a letter or
certificate from your educational institution that confirms your enrolment. It
must include:
a. The name of the institution – preferably on their letterhead.
b. Name of the student.
c. Course of study being undertaken.
d. Year of study. Full Time or Part Time.
e. Confirmation of payment of fees if applicable (student loan draw down
certificate is acceptable).
f. Signed and dated by the Registrar of Head of Department.
Pursuant to the PRIVACY ACT 1993 the following is brought to your attention:
1. This application collects personal information about you.
2. The information is collected to evaluate your application for an Education Grant.
3. The intended recipients of the information are the committee of Rotoma No. 1
Incorporation.
4. The information is being collected and held by Glenn Hawkins and Associates,
Rotorua.
5. You have the right of access to, and correction of, this information subject to the
provisions of the Privacy Act.
(Please print clearly)
PART A
APPLICANT’S DETAILS
a) Title:
b) Surname:
c) First Name:
d) Middle Name(s):
e) Gender (please tick):
f) Date of Birth:
Female
Male
______ / ______ / ______
g) Postal Address:
h) Suburb:
Town/City:
i) Postal Code:
j) Home Phone:
__
(
)
Mobile:
(
)
k) Email:
..................................................................................................................................
BANK ACCOUNT DETAILS
a) NZ Bank Account Number:
Bank
Branch
Account number
Suffix
NOTE: It is your responsibility to provide an accurate bank account number and to
attach to this application a verified bank deposit slip.
PART B
EDUCATION DETAILS & ENROLMENT CONFIRMATION
a) Tertiary Institution Name:
b) Study Status:
Full Time
Part Time
c) Full qualification name:
d) NZQA (or similar) Level of Qualification (please circle):
Certificate
Diploma
Degree
Masters
e) Course length fulltime (circle one):
Post Graduate Diploma
Doctorate
1 year
2 Years
3 Years
4 Years
Other _________
f) Course Start Date: ______ / ______ / ______
Course End Date: ______ / ______ / ______
g) Year of study in 2015 (circle one):
1st
2nd
3rd
4th
h) Upon Graduation, what career do you plan to pursue:
i) I have attached confirmation of Full Time Enrolment including:
a. The name of the institution.
b. Name of the student.
c. Course of study being undertaken.
d. Year of study. Full Time or Part Time.
e. Confirmation of payment of fees.
f. Signed and dated by the Registrar of Head of Department.
Yes
No
5th
6th
PART C
WHAKAPAPA
Please show clearly that you are a current shareholder OR a descendant of a current
shareholder of Rotoma No. 1 Incorporation OR a descendant of the nominated
tupuna of a Whanau Trust.
If this information is inaccurate or incomplete, your application will be declined
 I am a current shareholder.
Please provide your name as recorded in the shareholder register:
_________________________________________
 I am a son/daughter/grandchild/great grandchild of a current shareholder or
tupuna of a Whanau Trust.
Please provide the side of your whakapapa which includes the shareholder in the
spaces below:
WHANAU TRUST
WHAKAKPAPA SHEET – ROTOMA NO. 1 INCORPORATION
TUPUNA OF WHANAU TRUST
YOUR RELATIONSHIP TO THE
TUPUNA EXPLAINED
SHAREHOLDER
WHAKAKPAPA SHEET – ROTOMA NO. 1 INCORPORATION
GREAT GRANDPARENT
GRANPARENT
PARENT
APPLICANT
a) Whakapapa certification – You must have your whakapapa confirmed by a
Shareholder or Trustee of the Whanau Trust
Certifier’s name:
Certifier’s role:
 Shareholder
 Trustee of Whanau Trust
Certifier’s signature:
DECLARATION
 All the information I have given in this application is true.
 I have read and understood the information about each section of this application
form.
 I understand that if my application is incomplete, it will not be considered.
 If I am a successful applicant, I agree that my award success, personal details and
photograph may be used by Rotoma No.1 Incorporation to promote the education
programme.
Student’s Name: ______________________________________
Signature: ______________________________________
Date: ______ / ______ / ______
CHECKLIST
Bank Account Details: I have attached a verified bank deposit slip
Enrolment Confirmation from Institution: I have attached a
confirmation of FULL TIME ENROLMENT form from my tertiary
institution
Proof of Fees paid: I have attached a receipt from my tertiary
institution showing fees are paid OR a copy of your drawdown
certificate
Whakapapa Sheet: I have completed Part C and this has being
signed by the shareholder OR trustee of the Whanau Trust
IMPORTANT: Attached all the above documents to this application,
and forwarded to the Secretary by 4.30 pm Friday, 29th May 2015
IMPORTANT INFORMATION
 Applications, including missing or corrected information, must reach Glenn
Hawkins & Associates by 4.30 pm, 31 May 2015. (please note: this is a Sunday, so
therefore applications need to be received by Glenn Hawkins & Associates by
4.30pm, 29 May 2015)
 Late applications or information will not be accepted after the closing date.
 Applicants must complete the appropriate application form for the year of
proposed course of study or training.
 You can also apply for the targeted scholarship, however if successful you will
only be awarded one.
 Neither Rotoma No. 1 Incorporation or Glenn Hawkins & Associates accept any
responsibility for lost or delayed application packages caused by incorrect
mailing instructions and/or address.
Glenn Hawkins & Associates
Level 5, Zens Centre
1135 Arawa St, P O Box 1712, Rotorua,
Phone (07) 348 3599 Fax (07) 348 3599
If you have any questions, do not hesitate to contact
the office of Glenn Hawkins & Associates