Please fill in the applicant’s details

Name:

University:

Faculty:

Judges use only

Prize of Excellence
for Tertiary Students of Victoria
2010 Application Form
 The Prize of Excellence
for Victorian Tertiary Studies

Background:
The Prize of Excellence for Victorian Tertiary Studies was established in 2005 with the aim of encouraging academic
excellence and community involvement amongst full time students who are enrolled at any tertiary educational
establishment in the state of Victoria.
The scheme is absolutely non-discriminatory. There is no restriction on an applicant's background based on nationality,
residency, ethnicity or faith. It is also not means nor income tested.

Eligibility requirements:
A full time student enrolled at an accredited tertiary educational institution in the state of Victoria.

Selection criterion:
Each application will be vetted by a panel of academic and community experts representing a broad spectrum of
Victorian society. Applications will be judged against the following criterion:
 Academic excellence (1/3 weighting)
 Voluntary community service (1/3 weighting)
 Personal interview of short-listed candidates (1/3 weighting)

Application Dateline:
Application must be submitted by mail on or prior to 31 Aug 2010 to:
Prize of Excellence for Victorian Tertiary Students
c/o Mekong Noodle House
241 Swanston Street, Melbourne 3000

Donors:

Ms. CINA CHOI KIMURAKAN Japanese Cafe

( ) Mr. Dee Lin
Prize Valued at $10,000 Prize Valued at $3,000 Prize Valued at $1,000
Part 1:
Applicant details
Recent Photo

1. Name of Applicant

Title (Mr/Miss/Ms) _________

First Name _________________________Last Name _______________________

2. Resident Address
___________________________________________________________________________postcode ____________

3. Postal Address
___________________________________________________________________________postcode ____________

4. Telephone numbe
Home ____________________________________Mobile _____________________________________________

5. Email address ______________________________________________________________________________

6. Date of Birth ___________________________ 7. Place of Birth______________________________________

8. Place of Origin __________________________ 9. Nationality________________________________________

10. Name of University___________________________________________________________________________

11. Campus ___________________________________________________________________________________

12. Course ____________________________________________________________________________________

13. Year _____________________14. Student ID _____________________________________________________

15. Are you a local/overseas student?  Local  Overseas

16. Major Subject and marks

Subjects Marks
____________________________________________________________________________________
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Attached: A copy of last year’s academic final result which shows the mark of the subjects.

Additional copies of this form can be downloaded from tsf.org.au and asianmultimedia.com.au
or picked up from Mekong Noodle House - 241 Swanston Street, Melbourne 3000
Part 2: Judges use only

Applicant overview

1. Are you involved in any student club activities?  Yes  No

2. Please describe the role you take in the club ?

____________________________________________________________________________________________

Please answer each question and attach additional pages if needed.

3.Are you involved in any community/charity service?

____________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________
4.Why are you applying for this prize?

____________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________
_______________________________________________________________________________________________

5.How would you use this prize?

____________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________

_______________________________________________________________________________________________

6.Please provide at least one referee

1) ____________________________________________________Contact details___________________________

2) ____________________________________________________Contact details___________________________

Relationship to the applicant 1) __________________________________ 2) ________________________________

Check List of Supporting Information
 A copy of last year’s academic final result which shows the mark of the subjects.
 A recent Photo
 At least one letter of reference.
 Supporting evidence of community service.

Declaration
I state that the information in this application and attachments is to the best of my knowledge true and correct.
I understand that this is an application only and may not necessarily result in prize approval.

Signature __________________________________ Date_____________________________

Printed name _______________________________________________________________
This form should be posted to: Prize of Excellence for Tertiary Students of Victoria Application

c/o Mekong Noodle House

241 Swanston Street, Melbourne 3000