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
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