Application Form - Ngati Koata Trust

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.