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International StudentMemorial Fund Application Form

As part of our mission to inspire and empower our students, William Angliss Institute Foundation was established to provide educational opportunities and financial assistance to students.This fund has been established to commemorate the lives of two William Angliss Institute international students from Indonesia, who tragically losttheir lives in the 2009 Victorian Bushfires.

General Information for applicantsScholarship applicants should note the following:

TobeeligiblefortheMemorialFundyouMUST qualify as an International Student and hold a valid student visa for the period you are applying.

Forvariousscholarshipsinformation,includingrelevantclosingdates,pleaserefertotheWilliamAnglissInstitutewebsite www.angliss.edu.au/foundation

ThescholarshipwillbeawardedbytheFoundationBoardontherecommendationoftheWilliamAnglissInstituteFoundationSelectionCommittee. The decision is final.

ScholarshippaymentswillbemadetwoweeksafterthecommencementofSemester1andSemester2.

ThesuccessfulapplicantmayberequiredtoparticipateinrelevantpublicityeventsonbehalfofWilliamAnglissInstitute.

Application Instructions1.Carefullyreadtheeligibilitycriteriaandtermsandconditionsapplicabletothisbursarywww.angliss.edu.au/foundation

2.Completeallsectionsinblocklettersillegiblehandwrittenapplicationswillnotbeconsidered.

3. Ensure you enclose copies of all supporting documentation with this application:

Academictranscripts

Photocopyofyourpassportandstudentvisa

Evidenceoffinancialhardship(ifapplicable)

Writtenassessmentfromateacherorstudentcounsellor(ifapplicable)

Letterfrommedicalpractitioner(ifapplicable)

Additionalinformationthatsupportsyourapplication.

4. Sign and date the application form

5. The application form and other relevant documentation must be completed and submitted in person by no later than 15 November forSemester 1 and 30 May for Semester 2 to the International Student Office at William Angliss Institute:

International Student Office William Angliss Institute GroundFloor,BuildingB 555LaTrobeStreet MelbourneVIC3001

6. This application is the property of William Angliss Institute. Supporting documentation will NOT be returned.

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Scholarship NamePleaseinsertthetypeofthescholarshipyouareapplyingfor: (pleaseselectoneoptiononly) Merit/AcademicAchievement Equity

Application DetailsAre you a currently enrolled William Angliss Institute student? Yes No

If yes, please provide Institute ID number:

CourseCode: CourseName:

Campus: StudyMode: Full-time Part-time Flexibledelivery

Personal Details Title: Mr Mrs Ms Dr Other

Familyname(asshowninpassport):

Givenname(s): Englishname(Ifyouuseone):

Date of Birth: D D / /M M Y Y Y Y Sex: Male FemaleCurrentAge: Firstlanguage:

Citizenship(asshowninpassport): Countryofbirth(asshowninpassport):

Home address in home country Home address in Australia

Address: Address:

Province: Postcode: Suburb:

Country: State: Postcode:

Home address valid from: D D / /M M Y Y Y Y to: D D / /M M Y Y Y Y ArEACodE

Telephone: () Telephone: ()

Mobile: () Mobile:

Fax: () Fax: ()

Email(mandatory): Email(mandatory):

Visa-related InformationPassportNumber: Expirydate: D D / /M M Y Y Y YAre you currently in Australia? Yes No

If yes, state your visa type (eg student, etc) visa subclass number and expiry date:

Visa Type: Subclass No: Expirydate:D D / /M M Y Y Y YHave you applied to become a permanent resident of Australia? Yes No

If yes, date of application: D D / /M M Y Y Y Y Please submit a certified copy of your visa and passport with this application.

Reason/grounds for application Academic Achievement Merit

Medical Personal Financial Disability

Other:

*Pleasenote:ifyourapplicationisonmedical/psychologicalgroundsyoumustsubmitacertificatefromaregisteredpractitioner.

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Written statementPleasesupplyawrittenstatement(maximum600words)supportingyourapplication.Ifthereisnotenoughroombelow,pleaseattachanyadditionaldocuments.

Your statement should address your reason for applying for the scholarship and if required, the selection criteria relevant to the scholarshipyouareapplyingfor(pleaserefertowww.angliss.edu.au/foundation.)

Please provide any additional documentation that may complement your application.

Contact details of two referees Ifyouareapplyingonthebasisofacademicexcellence,yourrefereemustbetheWilliamAnglissInstitutestaffmemberwhonominatedyou

forthis scholarship.

Ifyouareapplyingonthebasisofequity(medical,disabilityandfinancialhardship)yourrefereecanbetheWilliamAnglissInstitutestudentcounsellor,yourGP,orWAIInternationalStudentofficer.

Inaddition,youmayalsoprovideapersonalorprofessionalrefereetosupportyourapplicatione.g. an employer.

Referee 1: Referee 2 (optional):

Name: Name:

Position: Position:

Organisation: Organisation:

Relationship to referee: Relationship to referee:

Telephone number: Telephone number:

Mobile: Position:

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Checklist Completedallquestionsontheapplicationform

Attached your written statement/s addressing the selection criteria

Providedrefereedetails

Submitted a copy of your current visa and passport with your application

Submitted academic results from the most recent semester

Submittedevidenceoffinancialhardship(ifapplicable)ieBankStatements,etc.

Submittedletterfrommedicalpractitioner(ifapplicable)

Submitted a copy of any relevant information that would support your application

readandunderstoodthetermsandconditionsofthescholarshipapplicationprocess(availableatwww.angliss.edu.au/foundation)

Signed the application form

Enclose all supporting documentation with this application

I understand that this application is the property of William Angliss Institute. Supporting documentation will NOT be returned.

Please note: As part of the assessment process you may be required to submit additional information.

DeclarationIdeclarethattheinformationprovidedis,tothebestofmyunderstandingandknowledgecompleteandcorrect.Iamawarethatthereareseverepenaltiesforprovidingfalseormisleadinginformation.IunderstandandacknowledgethattheremaybeaneedforWilliamAnglissInstitutetosharemyinformation with athird party, such as donors and sponsors etc. I give my permission for William Angliss Institute to supply any relevant official records in accordance with the terms and conditions and privacy legislation.

Signature: Date: D D / /M M Y Y Y Y

Submitting the applicationTobeeligible,applicationsmustbesubmittednolaterthan15NovemberforSemester1and30MayforSemester2.

The application form and other relevant documentation must be completed and submitted to International Student Office:

International Student Office William Angliss Institute GroundFloor,BuildingB 555LaTrobeStreet MelbourneVIC3001

Office use only

Scholarship application: Merit Equity

Scholarship successful:

Scholarship unsuccessful:

Approved by: (Name)

Signature: Date: D D / /M M Y Y Y Y