Application Form - Ngati Koata Trust

NMIT KAIAPA “JACK” KOHEMEMORIAL SCHOLARSHIPApplication Form 2013AimEach year Ngāti Koata Trust & NMIT will support a student who has enrolled and been accepted tostudy at NMIT. This programme or course of study will be required to enhance Iwi ki Te Tau Ihu o TeWaka ā Māui.BackgroundKaiapa “Jack” Kohe – was a Kaumātua (known as Uncle Jack) for NMIT for 5 years. He was veryinstrumental in setting many firsts for the then Nelson Polytechnic including a Te Tīriti o Waitangipolicy, Te Tīriti o Waitangi Academic Standards, Pōwhiri, Poroporoaki and Tikanga inserts inprogrammes and courses in several areas.Applicant name:Address:Term address:(if different from above)Email address:Home ph:Cell ph:_________________________________________________________________________________________________________________________________________________________Postcode______________________________________________________________________________________________________________________________________________________________________________________________________________2013 NMIT STUDY DETAILSProgramme name:Length:Part-time/full-time:Campus:Fees:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Course related costs: (e.g. Travel, childcare, textbooks, equipment) ___________________________Please ensure you supply the following when applying for your scholarship/s:1. A completed Application Form2. Two letters supporting your application e.g. from a tutor, past employer, family member3. Signature from your Iwi/Rūnanga Authority or Kaumātua (Elder) on WHANAU DETAILS: page 34. A copy of the letter confirming your acceptance onto the programme

Please provide a brief introduction about yourself.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________How will this study enhance your future goals?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Why would you be a worthy scholarship recipient? (The selection panel will be considering your financialsituation and potential to succeed in your field of study).________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

WHANAU DETAILS:WHAKAPAPA:A full disclosure of your whakapapa back through your lineage to aknown Māori ancestor is required. You may be asked to provide acopy of your birth certificate.Great great GrandfatherGreat GrandfatherGreat great GrandmotherGrandfatherGreat great GrandfatherGreat GrandmotherGreat great GrandmotherFatherGreat great GrandfatherGreat GrandfatherGreat great GrandmotherGrandmotherGreat great GrandfatherGreat GrandmotherGreat great GrandmotherYouGreat great GrandfatherGreat GrandfatherGreat great GrandmotherGrandfatherGreat great GrandfatherGreat GrandmotherGreat great GrandmotherMotherGreat great GrandfatherGreat GrandfatherGreat great GrandmotherGrandmotherGreat great GrandfatherGreat GrandmotherGreat great GrandmotherRūnanga/Iwi Authority or Kaumātua signature which verifies this as a true record:Signed:Date:

Will you receive funds from any other sources?Student LoanYes / NoStudent AllowanceYes / NoWork & Income NZ - TIA, Other Yes / NoOther scholarshipsYes / NoOther (please specify) _______________ ___________NMIT Scholarship applicants should be aware that successful scholarship applicants must agree tothe following conditions: agree to participate in any promotions associated with the scholarship, andshould the scholarship recipient leave NMIT before the completion of their studies, that they willreturn the full amount of the scholarship to NMIT.Applicant's signature which verifies this as a true record:Signed: ____________________________Date: ________________________Please ensure your scholarship application is accompaniedby at least TWO letters of support/references.PRIVACY ACT:The information in this Application Form will be used only for the purpose of assessing your application forthe Kaiapa “Jack” Kohe Memorial Scholarship. Personal information contained in this application will be madeavailable only to the members of the selection panel and administration staff.Letters of support/references will be considered confidential to the application. Please ensure onlyphotocopies are attached as documents will not be returned to you.I, , agree to the above conditions in respect of my application. Ihave read and understood the criteria for the Kaiapa “Jack” Kohe Memorial Scholarship. Should myapplication be successful, I agree to the publication of my name and programme of study as a recipient of theKaiapa “Jack” Kohe Memorial Scholarship.CLOSING DATE: Applications must be received by NMIT Scholarship Co-ordinator no later than 2pm,20 March 2013.