application form.pdf - Universities New Zealand - Te Pōkai Tara

Application Form Page 1SURNAME………………………………….NSN ………...…………………………….The Kauri Museum Mervyn Sterling Memorial Scholarship(School Leavers)Application ChecklistYour application must be completed and returned to the Scholarships Manager,Universities New Zealand – Te Pōkai Tara, PO Box 11915, Wellington 6142, by 1December.You must correctly fill out the application form and include all documents listedbelow and requested in the Regulations. Incomplete applications will not beconsidered.Please tick documents attached:√Universities New Zealand Application Form page 1 (Checklist)Universities New Zealand Application Form page 2Universities New Zealand Application Form page 3Universities New Zealand Application Form page 4Universities New Zealand Privacy Form page 5Certified copy of your Birth Certificate and proof of New Zealand citizenshipor permanent residency (if not born in New Zealand)Certified copies of your academic records to dateWritten statement giving details of your affiliations to the old OtamateaCounty AreaThis form must be received by 1 December

Application Form Page 2SURNAME………………………………….NSN ………...…………………………….The Kauri Museum Mervyn Sterling Memorial ScholarshipPERSONAL DETAILSNAME IN FULL: .........................................................................................................Permanent Address: ...............................……………………………………………………………………............…………………………………………………………………………………………………………………………………….………………….……………………………………………………………………………………………………………………………………….………………Telephone: ….…………………………………………………. E-mail: …….…………………………………………………………Mobile Phone: ………………………………………………… Date of birth: …………………………………………………….Secondary school(s) attended: ..................................................................................................ARE YOU A NEW ZEALAND CITIZEN? (Please circle one) Yes NoARE YOU A PERMANENT RESIDENT OF NEW ZEALAND? (Please circle one) Yes NoSchoolingYear 12/NCEA Level 2 (or equivalent) Subjects and Grades1:...................................... 2:...................................... 3:......................................4:...................................... 5:...................................... 6:......................................Year 11/NCEA Level 1 (or equivalent) Subjects and Grades1:...................................... 2:...................................... 3:......................................4:...................................... 5:...................................... 6:......................................UniversityWhich tertiary institution will you attend next year: ............................................................In which year will you begin tertiary study: .......................................................................Which degree/qualification will you enrol for: .....................................................................What subjects do you plan to study in your first year: .........................................................State briefly why you have chosen this course of study: .....................................................................................................................................................................................................................................................................................................................................................................................................................................................................This form must be received by 1 December

Application Form Page 3SURNAME………………………………….NSN ………...…………………………….GeneralApplication Form Page 3Other qualifications and/or courses of study undertaken:...............................................................................................................................................................................................................................................................................................................................................................................................................Have you applied for any other scholarships to assist you at university? If so, give details: ...........................................................................................................................................Recreational interests: (Give details of sports, cultural or service interests, both within andoutside of school)...............................................................................................................................................................................................................................................................................................................................................................................................................Proposed future occupation: ......................................................................................................................................................................................................................................................................................................................................................................In this space add any additional information which you feel could assist your application: .................................................................................................................................................................................................................................................................................REFEREESGive the names of two persons of standing whom you have asked to report in confidence directto Universities New Zealand on your academic achievements and abilities. IN ADDITION youwill need to ask your school principal to submit a reference or testimonial direct to UniversitiesNew Zealand.Name: ................................................... Name: ....................................................Address or e-mail: ................................... Address or e-mail: ................................................................................................. ..............................................................Give the name of one further referee, not a teacher, whom you have asked to report direct toUniversities New Zealand on your general character, qualities of leadership etc.Name: ….………………………………………………………..Address or e-mail: ………………………………………______________________________________________________________________________________DECLARATIONI have read and understood the regulations for The Kauri Museum Mervyn Sterling MemorialScholarship and agree to abide by them.Date: ...................................... Applicant’s signature: ................................................This form must be received by 1 December

Application Form Page 4SURNAME………………………………….NSN ………...…………………………….ACADEMIC RECORDUniversities New Zealand will obtain Year 13 exam results from NZQA. IB and Cambridgecandidates must forward to Universities New Zealand IMMEDIATELY a certified copy of theirresults by courier or fastpost as soon as they are received.NCEA (including Scholarships)NSN ……………………………………….Subject Level Subject LevelE.g. English Level 3 E.g. History NZScholarshipCIECANDIDATE NO ………………………Subject Level Subject LevelIBCANDIDATE NO ………………………Subject Level Subject LevelThis form must be received by 1 December

Application Form Page 5SURNAME………………………………….NSN ………...…………………………….UNIVERSITIES NEW ZEALAND PRIVACY FORMThe information that you have provided in this form and your academic record will be used for thepurposes of assessing your application for the award. Personal information contained in yourapplication will be made available to members of the Selection Committee for this award, themembership of which is detailed in the award regulations. In assessing your application UniversitiesNew Zealand will use references from third parties nominated by you.In the event that you are successful in gaining an award or are selected as a reserve candidate foran award Universities New Zealand undertakes to store your application in a secure place. In theevent that you are unsuccessful in gaining an award Universities New Zealand undertakes todestroy your application to preserve its confidentiality.Should you have reason to believe that information held about you in either your application or youracademic record is incorrect, you have the right of access to, and correction of, that information.Personal references from the persons you have named are obtained on the strict understandingthat they are confidential, and you may not have access to those reports through Universities NewZealand.Applicants shall agree to Universities New Zealand obtaining their academic results fromorganisations such as NZQA, necessary to assess their application.Applicants shall agree to co-operate with any publicity of the award for which they have applied.Such publicity may include material provided with your application, photographs and interviewswith award recipients.I, …………………………………………………………… agree to the above conditions in respect of this application.Signed: ................................................ Date: ..........................................................This form must be received by 1 December

ADVICE TO APPLICANTSApplications must arrive by the date shown on the application form. No undertaking is given toaccept late applications.It is your responsibility to contact your referees and ask them to submit their reports on time.Referees should not be asked to send their reports to you as they must have the opportunity to becompletely frank.References must be clearly marked with your full name and the name of the scholarship for whichyou are applying.Please do not send original birth certificates or other original documents. Send only copies thathave been certified by a J.P., a solicitor, or a staff member in your university, or school principal.Please do not send a CV unless this is specifically requested.Universities New Zealand accepts no responsibility to return any documents.Please do not put your application into any sort of folder. Simply attach all pages with ONE staplein the top left hand corner. All pages should be A4 size.If you have any queries regarding your eligibility or how to apply, please contact the ScholarshipsOffice at your university or scholarships@universitiesnz.ac.nzThis form must be received by 1 December

REFEREE’S REPORT (UNDERGRADUATE)Applicant’s Name: .......................................................................................Applicant’s School: ......................................................................................Scholarship(s) Applied for: ...........................................................................This report is due by: 1 December____________________________________________________________________Please provide a confidential reference (academic or personal) for this applicant.This reference will only be used by the Selection Committee in considering the candidate’sapplication.You may use this form or attach a separate document to this formPlease send this report• To the Scholarships Manager at Universities New Zealand, PO Box 11915, Wellington 6142Referee’s Name: (Please print) .................................................................................Position: ................................................................................................................Signature: .............................................................. Date: .....................................

REFEREE’S REPORT (UNDERGRADUATE)Applicant’s Name: .......................................................................................Applicant’s School: ......................................................................................Scholarship(s) Applied for: ...........................................................................This report is due by: 1 December____________________________________________________________________Please provide a confidential reference (academic or personal) for this applicant.This reference will only be used by the Selection Committee in considering the candidate’sapplication.You may use this form or attach a separate document to this formPlease send this report• To the Scholarships Manager at Universities New Zealand, PO Box 11915, Wellington 6142Referee’s Name: (Please print) .................................................................................Position: ................................................................................................................Signature: .............................................................. Date: .....................................