The CooperAitken James Houghton Memorial Scholarship
Name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Place of birth
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Schooling History:
Academic Achievements to date:
Community & Individual Achievements and Involvement to date:
Long term career objectives:
Qualification you have enrolled in
Qualification provider
Start date of your qualification
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Expected completion date of your qualification
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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Referees
Referee 1
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to you
Can we contact the referee in regard to your application?
Yes
No
Referee 2
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to you
Can we contact the referee in regard to your application?
Yes
No
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What other funding/scholarships have you applied for?
Bank Account Number:
Income Sources: (e.g. Wages, Studylink, Contributions, Savings)
Detail Course Expenses:
How did you hear about this scholarship?
Internet Search
Advertising
Word of mouth
School
Other
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Confirmations:
Please tick to confirm your acceptance of each statement
a) I understand the Panel may seek further information from me and/or my referees when considering my application.
*
I agree
b) I understand I may be asked to attend an interview with the panel
*
I agree
c) The Panel are committed to selecting the most suitable recipients in accordance with the Scholarships purpose and guiding principles
*
I agree
d) All scholarship monies will be used for the purpose for which I have applied and will be used within six months from the date I receive the funds. I am obliged to refund the money if I receive funding from a different source for the same purpose. I will provide copies of all invoice, receipts and bank statements if required to do so by the Panel to confirm proof of expenditure.
*
I agree
e) I will comply with any request from the Panel for additional information in relation to how the monies have been spent by me.
*
I agree
f) The information I have provided is true and correct to the best of my knowledge.
*
I agree
Signature
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
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