Edith Cowan University
Inspiring Minds Equity ScholarshipsApplication FormImportant informationApplicants are strongly advised to read the Inspiring Minds Equity Scholarship – Applicant information document, prior to completing and submitting their application.All sections on the application form must be completed and it is the responsibility of the applicant to provide relevant supporting documentation at the time of submission or the application may not be considered. Applicant DetailsFirst NameClick here to enter text.SurnameClick here to enter text.Student IDClick here to enter text.Student emailClick here to enter text. Please ensure that your correspondence address details are updated on SIMOYou must be able to answer ‘Yes’ to questions 1 - 3 in order to meet the eligibility criteria for this scholarship.Are you currently enrolled or intending to enrol in a full time load (60 credit points) for semester 2, 2016??Yes I am enrolled ?Yes, I am intending to enrol Have you completed a minimum of 60 credit points in your current course? (excluding any Advanced Standing) ? Yes Have you achieved consistent pass grades? ? YesFinancial and Personal CircumstancesPlease confirm that you are one of the following : - ? Australian Citizen ? Australian Permanent Resident ? New Zealand Citizen Are you from a rural, regional or remote area of Australia? ?Yes ?No Did you relocate from a rural, regional or remote area of Australia in order to study??Yes ?No Please provide Suburb and postcode of rural, regional or remote address Suburb Click here to enter text. Postcode Click here to enter text. How long did you reside in a rural, regional or remote address? From (year ) Click here to enter text. to (year) Click here to enter text. Are you of Australian Aboriginal and/or Torres Strait Islander descent??Yes ?No Do you or someone you care for have a disability or ongoing illness that significantly effects your ability to study??Yes ?NoAre you registered with the ECU Equity Diversity and Disability Office? ?Yes ?No Are you personally in receipt of a means tested allowance from Centrelink or the Department of Veterans Affairs? ?Yes ?No If you are a Centrelink Customer please ensure you complete the Centrelink Consent form - (page 4 of the application form) providing your Centrelink Customer reference numberIf you are a recipient of a Department of Veterans Affairs allowance then please provide evidence of this. If you are not in receipt of a Centrelink allowance please outline any reasons why you may be financially disadvantaged and why Centrelink does not recognise your circumstances?Click here to enter text.Please confirm what is your monthly combined household income? $ per month Please note that a combined figure requires you to provide a total of monies received by all members of your household, i.e. parents, partners, all adults in home. Are you the holder of a valid current Health Care Card??Yes ?NoAre you currently in receipt of any other scholarships or awards? ?Yes ?NoHave you previously received the Inspiring Minds Equity scholarship??Yes ?NoPlease identify your living situation during 2016. Single (living with parents/guardians/family members) ? Single (living away from home/financially supported by parent/guardian? Single(living away from home/financially independent? Single with dependants ? Partnered with no dependants ? Partnered with dependants ? Other (please describe in space below)?Click here to enter text.Please provide information relating to your circumstances, either past or present which have had a significant impact on your life and capacity to give time and attention to your studies.Click here to enter text.Please provide a statement outlining your personal goals or what you hope to achieve upon completion of your studies and how this scholarship will help you achieve these goals.Click here to enter text.Checklist – Please tick to indicate that you have attached the following supporting documentation to this application form. Failure to provide supporting documentation may affect you receiving a scholarship offer. Please read the Inspiring minds Equity Scholarship – Applicant information document, to confirm what documents are required.?Evidence of Citizenship or residency status?Completed Centrelink Customer Consent form if you are a Centrelink Customer?Copy of recent Centrelink Statement if you are a Centrelink Customer ?Evidence of being a recipient of a Department of Veterans Affairs grant/payment?Evidence of your rural address (i.e. drivers licence, high school report, official document with your full postal address on it – not PO Box) if you have relocated.?Evidence of current address if you have relocated?Evidence of any dependantsStudent Declaration I declare that the information I have supplied within this application is true and correct to the best of my knowledge. I understand if any false or misleading information is provided it could lead to the cancellation of my scholarship. I also understand giving false or misleading information is a serious offence under the Criminal Code. I consent to the disclosure of relevant information for the selection process of this scholarshipSignature of Applicant: Click here to enter text.Date:Click here to enter a date.Centrelink Confirmation e Services (CCeS)Customer Consent RecordCentrelink Confirmation eServices (CCeS) are internet-based facilities used by organisations like Edith Cowan University (ECU) to confirm a Centrelink or Department of Veterans' Affairs (DVA) customer's entitlement status to receive a concession or government allowance. CCeS assists Edith Cowan University to ensure the eligibility of scholarship applicants by providing information as follows:Centrelink EnquiryECU can utilise a Centrelink enquiry to:Confirm a Centrelink customer's entitlement to receive a concession.This type of enquiry only returns a YES or NO answer to Edith Cowan University.Confirm the type of allowance a Centrelink customer receives. This type of enquiry only provides the name of the allowance the Customer is entitled to.Department of Veterans' Affairs (DVA) EnquiryThis enquiry is identical to a Centrelink Enquiry, except that it is used to specifically check DVA customer’s eligibility for concessions.I (insert full name) Click here to enter text. authorise:Edith Cowan University (ECU) to use Centrelink Confirmation eServices to perform a Centrelink / DVA enquiry of my Centrelink or Department of Veterans’ Affairs Customer details and concession card status in order to enable the business to determine if I qualify for a scholarship.The Australian Government Department of Human Services (the department) to provide the results of that enquiry to Edith Cowan University (ECU).I understand that:The department will use information I have provided to Edith Cowan University (ECU) to confirm my eligibility for financial hardship and will disclose to Edith Cowan University (ECU) personal information including my name, address, payment and concession card type and status.This consent, once signed, remains valid while I am a customer of Edith Cowan University (ECU) unless I withdraw it by contacting Edith Cowan University or the department.I can obtain proof of my circumstances/details from the department and provide it to Edith Cowan University (ECU) so that my eligibility for a scholarship can be determined.If I withdraw my consent or do not alternatively provide proof of my circumstances/details, I may not be eligible for the scholarship/award provided by Edith Cowan University (ECU). ECU Student ID: Click here to enter text.Student E-mail: Click here to enter text. Centrelink or DVA Customer Reference Number (CRN) Click here to enter text.Signature:__________________________________________(hand written signature required)Date:__________________________________________ ................
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