Norman Kirk Memorial Trust Scholarships
Application Form – 2017


Applications close at 5.00 pm on 7 April

TYPE INTO THE FIELDS ON THIS FORM. LATE AND INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED.

PERSONAL DETAILS
Legal Family Name
Legal Given Name(s)
Street
Suburb/RD Number
Town/City / Postcode:
Home Telephone / ( ) / Cell phone ( )
Date of birth / Gender:
Citizenship / NZ citizen
Other (Please state): / Do you hold a NZ residence class visa? Yes No
Ethnicity
Student Email
Personal Email
ENROLMENT DETAILS
Tertiary Institution
Course of Study
Enrolment Status / Full-time / Part-time / Extra-mural
Year of Study / 1st / 2nd / 3rd / Other:
Length of Programme / Years / Months
Previous Qualifications
APPLICATION
This is my first application to PIPEF / Yes / I have applied to PIPEF/NKMT in previous years


Applicant’s Name:

CHECKLIST

The application and required documents must be submitted as a PDF file, and saved as one file. Documents received as a JPG or RAR file are not accepted. Scanned copies of academic results must be scanned in colour, of at least 300dpi resolution. You must include all pages of your academic results including the grading scale (if applicable). Make sure your name is on every page.

Read the declaration below, date it, print and sign

Take a copy of your application, for your record

PRIVACY PROVISIONS and DECLARATION

The personal information you provide in this scholarship application will be treated in accordance with the Privacy Act 1993. It will be used solely for the purpose of assessing your application, and will be held confidential to members of the PIPEF Board, PIPEF Board accountant, Ministry of Education and Audit New Zealand.

APPLICANT’S DECLARATION

I confirm that:

·  The information set out in this application form is true, accurate and complete; AND

·  I have read and understood the regulations for the NKMT Scholarship; and I agree to abide by them; AND

·  Should I be successful with this application, I give permission to the PIPEF Board to
use my profile and photo at no cost for PIPEF Board recruitment and marketing activities.

Applicant’s Name:

Signature: ………………………………………………………………… Date: / / 2017

Applicant’s Name:

CLOSING DATE
Applications close at the PIPEF Board Administrator at 5.00pm on 7 April 2017.
Email the complete application and supporting documents to .
Acknowledgement of receipt of application will be sent by email within 5 working days.
LATE AND INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED.
SUPPORTING INFORMATION (All are required)
A typed statement and evidence of hardship, including how the scholarship can assist your studies.
A typed statement outlining your involvement in the Pacific community.
Proof of NZ citizenship and NZ residence class visa (if applicable).
Proof of full-time enrolment and tuition fees payment at tertiary institution.
An academic reference.
A reference of your involvement in the Pacific community.
PIPEF Scholarship Financial Statement
A certified copy of your high school results (first year students only) or tertiary academic transcript(s).
A certified copy is a photocopy of an original document which has been certified as a true copy by a Justice of the
Peace, Solicitor or Notary Public.
Applicant’s Name:
FINANCIAL STATEMENT IN SUPPORT OF APPLICATION FOR PIPEF SCHOLARSHIP
Housing Situation / Living with Parents / Flatting / Own your own home / Halls of Residence / Other:
2017 BUDGET
Weekly Personal Income / Weekly Personal Expenses
Weekly wage/salary
(after tax) / $ / Mortgage/rent/bond / $
Spouse’s wage/salary (after tax) / $ / Rates (land/water) / $
Work & Income benefit / $ / Insurances:
Building
Contents
Car
Life
Medical / $
NZ Superannuation / $ / Superannuation / $
ACC / $ / Power (electric, gas) / $
Family Support / $ / Telephone / $
Child Support / $ / Food / $
Any other income (please specify e.g. rent, board) / $ / Clothing & footwear / $
Medical (doctor, dentist) / $
TOTAL / $ / Any other expenses (specify – i.e. travel) / $
Total Personal Assets
Money in any bank account: (specify accounts) / TOTAL / $
Cheque account / $
Savings account / $
Other account / $
Other account / $
Property
(state addresses) / $
Vehicle / $
Any other assets (please specify e.g. bonds, motor home…) / $
TOTAL / $