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PALLOTTINE ABORIGINAL
 SCHOLARSHIP TRUST

PRINTABLE APPLICATION FORM FOR 2009 SCHOLARSHIPS

 

NAME: ____________________________________________________________
               Title   First                    Middle                  Family

Date of Birth: ____/_____/_______

Place of Birth: _______________________________

Are you an Aboriginal or Torres Strait Islander Person?
                                                                            (Please tick) Yes No 

Permanent Address:__________________________________________________

____________________________________________________________________

Postal Address: ______________________________________________________

          _________________________________________________________

Telephone: _________________________ Fax: ___________________________

E-mail: __________________________

Current place of employment or schooling:

____________________________________________________________________

Last school attended: ________________________________________________

Year last attended: ___________________________________________________

Standard attained: ___________________________________________________

Any other courses completed:
          Year:              Place:                 Name of course:

____________________________________________________________________

____________________________________________________________________

Course you intend to study:

____________________________________________________________________

____________________________________________________________________

Nominate the institution where you intend to study:

____________________________________________________________________

Please nominate two people to act as referees: *Must not be a member of the scholarship committee

1. Name: ___________________________________________________________

Address: ___________________________________________________________

Telephone: Home ______________________ Work _______________________

2. Name:____________________________________________________________

Address:____________________________________________________________

Telephone: Home ______________________ Work _______________________

 

Name any community or Aboriginal organization in which you are or have been involved.

____________________________________________________________________

____________________________________________________________________

(Please tick)

At present on whom do you depend for support?
                                                                   Self   Family   Other

If other, please specify: ______________________________________________

If you obtain this scholarship who will support you?
                                                                   Self   Family   Other

If other, please specify: ______________________________________________

Have you ever received a scholarship?                            Yes     No   

If yes, please specify: ________________________________________________

Have you current applications for other scholarships?      Yes     No  

If yes, please specify: ________________________________________________

____________________________________________________________________

 

On a separate sheet, please indicate to the Scholarship Committee

  • your areas of career interest.
  • how might the Aboriginal community benefit if you received this scholarship?
  • you may also wish to comment on why you have chosen a particular course.
  • your future goals.
  • the length is determined by what you wish to outline to the Scholarship Committee, but we would suggest about 250 - 300 words. You may attach additional pages.

 

Your results from the semesters of study you completed in 2008
You must undertake to send to the committee your results for the last semester of 2008 before the 15th January 2009

Applications will be called for each year. They close on the 30th of September.

I declare that this Application for the Pallottine Aboriginal Scholarship is my own work and that all information provided is, to the best of my knowledge, true and accurate.

 

Signature of Applicant: __________________________________________

 

Date: _____________________________ Place: ______________________

 

Pallottine Aboriginal Scholarship Trust
60 Fifth Ave
Rossmoyne  WA   6148

Phone:  08 9354 0208
Fax:      08 9457 0344
Email:  pallcomm@wn.com.au  

Form from www.pallottine.org.au

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