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Please ensure you have read the: TERMS & CONDITIONS STUDENT IDENTIFICATION NUMBER: 9 Digit Number as shown

on any correspondence and Matriculation Card SURNAME: FIRST NAME: NUMBER OF EVENING DEGREE MODULES TO BE TAKEN: SEMESTER 1 SEMESTER 2 YEAR LONG MODULES

As our awards are based on Financial Need, please complete the following section to show your gross household income, (yourself and partner) per annum. Please note that should your application be successful you will be asked to provide proof of the information given here.
HOUSE HOLD INCOME : (If nil values, please leave blank) INCOME 1 Gross income from employment or pension (salary, wages, investments, bonuses, etc) Tax Credits/Family Allowances Social Security benefits Any other income TOTAL Household Income Do you intend to apply for a Part-Time Fee Grant or Part-Time Fee Waiver - (Yes/No)? If yes, which award to do you intend to apply for? PERSONAL STATEMENT & ADDITIONAL INFORMATION Please use this space to state in no more than 200 words why you wish to be considered for a scholarship. This personal statement should focus on your personal circumstances and need for support. Please see Terms & Conditions for Guidance 0.00 INCOME 2

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