Application Form - Family Planning NSW
Application Form - Family Planning NSW
Application Form - Family Planning NSW
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The Tony McGrane Rural Scholarship<br />
for Nursing in Reproductive Health<br />
<strong>Application</strong> <strong>Form</strong><br />
1. Title (Ms Mrs Mr) Surname<br />
Given Names<br />
2. Address:<br />
Postcode<br />
Postal Address (if different to above) ...............................................................................................................................<br />
Postcode<br />
Telephone (W) (H) (M)<br />
E-mail<br />
3. Are you an Australian citizen or permanent resident of Australia?<br />
Yes<br />
No<br />
Should your application be successful a certified copy of your birth certificate<br />
naturalisation papers, or other official documents such as a passport will be required.<br />
You are not eligible for the Tony McGrane Rural Scholarship for Nursing in<br />
Reproductive Health.<br />
4. Date of registration as a Registered Nurse/Registered Midwife .......................................................................<br />
(Please attach a copy of your current ‘Authorisation to Practice’ (Registration)<br />
5. Total length of service as a Registered Nurse/Midwife<br />
6. Current Employer (if applicable)<br />
7. Position Title:<br />
8. Date commenced this employment:<br />
9. Please describe your current clinical responsibilities: (current role, commitment to role, length of employment<br />
in rural or remote health - 250 words maximum)<br />
This scholarship is provided by <strong>Family</strong> <strong>Planning</strong> <strong>NSW</strong>
<strong>Application</strong> <strong>Form</strong><br />
Page 2<br />
The Tony McGrane Rural Scholarship<br />
for Nursing in Reproductive Health<br />
11. Please describe the service/practice (no. of clinicians, service offered, population size and location - 100 words<br />
maximum)<br />
12. Have you received a scholarship from any other organisation in the past three (3) years?<br />
Yes<br />
No<br />
If yes, please give details .............................................................................................................................<br />
.................................................................................................................................................................<br />
..................................................................................................................................................................<br />
13. Educational qualifications (Please attach copies of relevant documents)<br />
Award/Title Institution Year Awarded<br />
.................................................................................................................................................................<br />
.................................................................................................................................................................<br />
.................................................................................................................................................................<br />
14. Employment History (including dates of appointment or attach CV)<br />
Position held Employer Date of Position<br />
employment responsibilities<br />
This scholarship is provided by <strong>Family</strong> <strong>Planning</strong> <strong>NSW</strong>
<strong>Application</strong> <strong>Form</strong><br />
Page 3<br />
The Tony McGrane Rural Scholarship<br />
for Nursing in Reproductive Health<br />
15. Please state concisely your reasons for applying for the scholarship and address the scholarship criteria of how<br />
completing the Tony McGrane Rural Scholarship for Nursing in Reproductive Health will assist in improving the<br />
reproductive health outcomes for the rural or remote community you work with. (300 words maximum)<br />
Please attach further documentation if necessary.<br />
16. Please provide details of two referees.<br />
At least one referee must be a senior member of the nursing profession<br />
eg Manager/Director of Nursing/Clinician/Academic (Lecturer)/Women’s Health Coordinator<br />
(1) Name<br />
(2) Position<br />
(3) Telephone<br />
(1) Name<br />
(2) Position<br />
(3) Telephone<br />
17. I have read the terms of the scholarship and agree to abide by those terms if successful in my application.<br />
Signature of Applicant<br />
Date .<br />
Please return to:<br />
Director Clinical Services<br />
<strong>Family</strong> <strong>Planning</strong> <strong>NSW</strong><br />
Tony McGrane Rural Scholarship for Nursing in Reproductive Health<br />
328-336 Liverpool Road<br />
Ashfield <strong>NSW</strong> 2131<br />
Closing Date: 31 January 2012<br />
<strong>Application</strong>s will be accepted by fax or e-mail (hard copy must follow)<br />
FP<strong>NSW</strong>2012/McGAPP<br />
This scholarship is provided by <strong>Family</strong> <strong>Planning</strong> <strong>NSW</strong>
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