an accommodation

scholarship for rural

and regional students

Application Form
Applications for the 2011 Bendigo and Adelaide Bank Scholarship can be submitted by completing and emailing this Application
Form together with your tertiary admission score (scan) to foundation@bendigobank.com.au
Applications close at 4pm (AEDST) on Friday 28 January 2011. No late applications will be considered.
Before progressing further please:
 ensure that you have reviewed the Scholarship FAQ’s for further information and are confident the program fits your
circumstances;
 ensure you have read the Application Form Guidelines to assist you complete this application; and
 have a scanned (pdf) copy of your tertiary admission score available for uploading with your application. Please ensure that the
file name is the same as your full name.

1. Personal Details
Title:  Ms  Miss  Mrs  Mr
Given Name(s):
Surname:
Street Address:

Suburb:
State:
Postcode:
Postal address (if different from above):

Suburb:
State:
Postcode:
Telephone (home):
Mobile:
Email:
Are you still living at the family home at
 Yes  No
the time of submitting this application?
Date of birth:
Australian Citizen or permanent
 Yes  No
resident:

Community Enterprise Foundation™

Application Form (continued)
2. Secondary School
Name of secondary school / college:
Location of school (incl. State):
Type of school / student:  Public  Private – Boarding  Private – day student
In what year did you complete year 12?
Do you have any additional comments?

3. Academic Merit
Rank type:  ENTER  ATAR  TER  OP
Score:

Please provide evidence of your score by attaching a scanned copy of your tertiary admission score to your application email.

4. Secondary school leadership roles

Please provide below details of leadership roles you have undertaken within the school community.
Include involvement in teams, committees or special roles held.

5. Awards and scholarships received

Please provide details of awards or scholarships you have received whilst at secondary school.

6. Community achievements and leadership roles

Please provide details of volunteering activities, leadership roles and recognition awards from your community.

Community Enterprise Foundation™

Application Form (continued)
7. Tertiary Study
Have you received a confirmed offer
 Yes  No
from a university?
If Yes to the above, was this offered via
 Yes  No
the Special Entry Access Scheme?
Are you awaiting First Round offers in
 Yes  No
January?
Name of your first preference
university/college:
Location of university/college
(i.e. campus and state):
Full name of degree
(please include BA, BSc, etc):
Reason you chose this tertiary provider:

Name of your second preference

university/college:
Location of university/college
(i.e. campus and state):
Full name of degree
(please include BA, BSc, etc):
Reason you chose this tertiary provider:

Will you be receiving Centrelink

 Yes  No
payments in 2011?
Will you be studying full time in 2011?  Yes  No
Will you need to move away from home
 Yes  No
in order to take up tertiary study?
Is the duration of your course to be
 Yes  No
completed on campus in Australia?
Is this the first degree you will be
 Yes  No
undertaking?
Any additional comments?

Community Enterprise Foundation™

Application Form (continued)
8. Your circumstances
Please provide a description of your circumstances, in particular social or financial situations, which prevent you undertaking
tertiary education. (150 words max)

9. Employment history
If you have undertaken paid employment whilst at secondary school or during a gap year, please provide details below.
(Please include position, name of business, responsibilities of role and duration of employment).

10. Other Scholarships

Have you applied for other (tertiary)  Yes  No
Scholarships? If yes, please provide details below
Scholarship 1
Name:
Offered by:
Value:
Purpose:
Was your application successful?  Yes  No  Pending
If you have not yet been notified, when
do you expect to hear?
Scholarship 2
Name:
Offered by:

Community Enterprise Foundation™

Application Form (continued)
Value:
Purpose:
Was your application successful?  Yes  No  Pending
If you have not yet been notified, when
do you expect to hear?

11. Intended living arrangements

Please answer only one section – either A, B or C

Section A – On-Campus
Have you applied for accommodation at
 Yes  No
a College on campus?
Was your application for on campus
 Yes  No  Pending
accommodation successful?
Please confirm accommodation cost
(weekly):
Please state name of College:

Section B – Off-Campus
(university owned)
Have you applied for university-owned
 Yes  No
off campus accommodation?
Was your application for university-
owned off campus accommodation  Yes  No  Pending
successful?
Please confirm accommodation cost
(weekly):

Section C – Off-Campus (private)

Do you intend to live in private rental
 Yes  No
accommodation?
Have you applied for private rental
 Yes  No
accommodation?
Have you secured private rental
 Yes  No  Pending
accommodation?
Please confirm accommodation cost
(weekly):
What is the type of rental (e.g. shared
private house or unit, etc)
Any additional comments?

Community Enterprise Foundation™

Application Form (continued)
12. Referees
Full name of Referee 1:
Role:
Organisation:
Contact telephone (B/H):
Mobile:
Relationship to you:
Full name of Referee 2:
Role:
Organisation:
Contact telephone (B/H):
Mobile:
Relationship to you:

13. Declaration
By submitting this application I declare
that the information supplied is true and
complete in every detail. I acknowledge
and accept that the provision of
incorrect information or the withholding
 I agree
of relevant information may result
in the withdrawal of any scholarship
funding which may be offered and this
withdrawal may take place at any stage
during the course of study.

The Bendigo and Adelaide Bank Scholarship is a management account of Community Enterprise™ Charitable Fund ABN 12 102 649 968
The Bendigo Centre, Bendigo VIC 3550. (S31807) (11/10)

Community Enterprise Foundation™