International Student

Memorial 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 applicants

Scholarship applicants should note the following:
To be eligible for the Memorial Fund you MUST qualify as an International Student and hold a valid student visa for the period you are applying.
For various scholarships information, including relevant closing dates, please refer to the William Angliss Institute website
www.angliss.edu.au/foundation
The scholarship will be awarded by the Foundation Board on the recommendation of the William Angliss Institute Foundation Selection Committee.
The decision is final.
Scholarship payments will be made two weeks after the commencement of Semester 1 and Semester 2.
The successful applicant may be required to participate in relevant publicity events on behalf of William Angliss Institute.

Application Instructions
1. Carefully read the eligibility criteria and terms and conditions applicable to this bursary www.angliss.edu.au/foundation
2. Complete all sections in block letters illegible hand written applications will not be considered.
3. Ensure you enclose copies of all supporting documentation with this application:
Academic transcripts
Photocopy of your passport and student visa
Evidence of financial hardship (if applicable)
Written assessment from a teacher or student counsellor (if applicable)
Letter from medical practitioner (if applicable)
Additional information that supports your application.
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
Ground Floor, Building B
555 La Trobe Street
Melbourne VIC 3001
6. This application is the property of William Angliss Institute. Supporting documentation will NOT be returned.

2608-V4 0913

Scholarship Name
Please insert the type of the scholarship you are applying for: (please select one option only)

Merit/Academic Achievement

Equity

Application Details
Are you a currently enrolled William Angliss Institute student?

Yes

No

If yes, please provide Institute ID number:

Course Code:

Course Name:

Campus:

Study Mode:

English name (If you use one):

Full-time

Part-time

Flexible delivery

Personal Details
Title:

Mr

Mrs

Ms

Dr

Other

Family name (as shown in passport):

Given name(s):
Date of Birth:

D D /MM/ Y Y Y Y

Sex:

Male

Female

Current Age:

First language:

Citizenship (as shown in passport):

Country of birth (as shown in passport):

Home address in home country

Home address in Australia

Address:

Address:

Province:

Suburb:

State:

Postcode:

Country:

D D /MM/ Y Y Y Y
to: D D / M M / Y Y Y Y

Postcode:

Home address valid from:

Area Code

Telephone:

( )

Telephone: ( )

Mobile:

( )

Mobile:

Fax:

( )

Fax:

Email (mandatory):

Expiry date:

Email (mandatory):

( )

Visa-related Information
Passport Number:
Are you currently in Australia?

Yes

D D /MM/ Y Y Y Y

No

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

Visa Type:
Have you applied to become a permanent resident of Australia?
If yes, date of application:

Expiry date: D

Subclass No:
Yes

D /MM/ Y Y Y Y

No

D D /MM/ Y Y Y Y

Please submit a certified copy of your visa and passport with this application.

Reason/grounds for application

Academic Achievement
Medical

Personal

Merit
Financial

Disability

Other:
*Please note: if your application is on medical/psychological grounds you must submit a certificate from a registered practitioner.

2608-V4 0913

Contact details of two referees

If you are applying on the basis of academic excellence, your referee must be the William Angliss Institute staff member who nominated you
forthis scholarship.
If you are applying on the basis of equity (medical, disability and financial hardship) your referee can be the William Angliss Institute
studentcounsellor, your GP, or WAI International Student Officer.
In addition, you may also provide a personal or professional referee to support your application e.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:

Written statement
Please supply a written statement (maximum 600 words) supporting your application. If there is not enough room below, please attach any
additionaldocuments.
Your statement should address your reason for applying for the scholarship and if required, the selection criteria relevant to the
scholarship you are applying for (please refer to www.angliss.edu.au/foundation.)

Please provide any additional documentation that may complement your application.
2608-V4 0913

Checklist
Completed all questions on the application form
Attached your written statement/s addressing the selection criteria
Provided referee details
Submitted a copy of your current visa and passport with your application
Submitted academic results from the most recent semester
Submitted evidence of financial hardship (if applicable) ie Bank Statements, etc.
Submitted letter from medical practitioner (if applicable)
Submitted a copy of any relevant information that would support your application
Read and understood the terms and conditions of the scholarship application process (available at www.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.

Declaration
I declare that the information provided is, to the best of my understanding and knowledge complete and correct. I am aware that there are severe
penalties forproviding false or misleading information. I understand and acknowledge that there may be a need for William Angliss Institute to share my
information 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 /MM/ Y Y Y Y

Submitting the application

To be eligible, applications must be submitted no later than 15 November for Semester 1 and 30 May for Semester 2.
The application form and other relevant documentation must be completed and submitted to International Student Office:
International Student Office
William Angliss Institute
Ground Floor, Building B
555 La Trobe Street
Melbourne VIC 3001

Office use only

Scholarship application:

Merit

Equity

Scholarship successful:
Scholarship unsuccessful:

Approved by:

(Name)

Signature:

Date:

2608-V4 0913

D D /MM/ Y Y Y Y