The Lyttelton Port Company Directors’ UC Scholarship
Application Form – 2016
Applications close at 5.00 pm on 15 August 2015
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 (
UC Student ID
Date of Birth:
(if applicable)
Gender:
Citizenship
NZ Citizen
)
Female
Male
Are you a NZ Permanent Resident?
Other (Please state):
Yes
No
Email
SECONDARY EDUCATION (For School Leavers only)
National Student Number (NSN)
Name of school currently attending
N/A
Final Year at School e.g. 2015
ACADEMIC RESULTS - YEAR 12 (For School Leavers Only)
Please indicate which school exams you sat in Year 12 (tick all that apply):
NCEA
IB
NCEA transcripts are not required. UC will access your results from NZQA.
I give permission for UC to contact my school regarding my academic progress.
IB Candidate Number:
CIE
I have attached a *certified copy of my AS and A Level results completed up to the end of
2014.
Other
Please state:
I have attached a *certified copy of my 2014 results.
*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.
The Lyttelton Port Company Directors’ UC Scholarship – APPLICATION FORM 2016
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Applicant’s Name:
ACADEMIC RESULTS – TERTIARY STUDY (For School Leavers Only)
Are you currently doing or have previously done STAR courses or other tertiary courses?
Yes
No
If yes, please list them below and attach a *certified copy of your results (your Canterbury academic record does
not need to be attached).
*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.
ACADEMIC RESULTS (For Non-School Leavers only)
Original or certified true copies of your academic results (your Canterbury academic record does not need to
be attached, if applicable).
INTENDED STUDY AT THE UNIVERSITY OF CANTERBURY
Note: SCHOOL LEAVERS - As a condition of applying for the scholarship, you must complete an application to
enrol at UC sometime between 6 October and 7 December 2015. Phone 0800 VARSITY or 0800 827
748.
Degree Programme
Major Subject
The Lyttelton Port Company Directors’ UC Scholarship – APPLICATION FORM 2016
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Applicant’s Name:
CHECKLIST
Attach your supporting information to your application form with a staple or paper clip:
- Do NOT put your application in any sort of folder
- All pages of your application must be A4, printed ONE side only
- Make sure your name is on every page
Read the declaration below, date it, print and sign
Read and complete all fields of the Scholarships Consent Form (For School Leavers with Year
12 NCEA Results Only)
Take a copy of your application, for your record
I confirm that I will complete an application to enrol at UC between 6 October and 7 December
2015.
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 selection committee and UC authorised staff.
APPLICANT’S DECLARATION
I confirm that:

The information set out in this application form is true, accurate and complete, and my
written statements are entirely my own work; AND

I have read and understood the Regulations for the Lyttelton Port Company Directors’ UC
Scholarship, and I agree to abide by them; AND

Should I be successful with this application, I give permission to the University of Canterbury
to use my profile and photo at no cost for University recruitment and marketing activities.
Applicant’s Name:
Signature: …………………………………………………………………
The Lyttelton Port Company Directors’ UC Scholarship – APPLICATION FORM 2016
Date:
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Applicant’s Name:
CLOSING DATE
Applications close at the UC Scholarships Office at 5.00pm on 15 August 2015.
Postal Address:
Scholarships Office
University of Canterbury
Private Bag 4800
Christchurch 8140
Courier Address:
Scholarships Office
University of Canterbury
20 Kirkwood Avenue, Ilam
Christchurch
Phone 03 364 2987, ext 4113
Address for Personal Delivery:
Information Desk
Student Services Centre, Matariki
University of Canterbury
University Drive
Ilam Campus
Acknowledgement of receipt of application will be sent by email within 5 working days.
LATE AND INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED.
ENQUIRIES
For further information, please contact the UC Scholarships Office:
Phone: 03-364 2987 (ext 4113), or 0800 VARSITY (0800 827 748)
Email: scholarships@canterbury.ac.nz
SUPPORTING INFORMATION
FINANCIAL STATEMENT
Attach a typed statement (one A4 page max) outlining the financial challenges
you are facing in entering tertiary education; AND
OTHER AWARDS HELD OR
APPLIED FOR
Attach a typed statement outlining any other scholarships or awards currently
held of applied for; AND
EMPLOYMENT
CONFIRMATION
Please provide your parent’s or guardian’s name, address and telephone
number for the Lyttelton Port Company to confirm their employment.
The Lyttelton Port Company Directors’ UC Scholarship – APPLICATION FORM 2016
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University of Canterbury
Scholarships Consent Form
“In submitting this scholarship application form I agree to my details [legal name, date of birth, NSN
number] being used for the purposes of applying for the award of scholarships administered by the
University of Canterbury. The information will only be accessed by necessary University staff and
provided to NZQA in order for them to release results to the University of Canterbury to support my
scholarship applications. I understand my data will be held securely and will not be distributed to any
third parties other than NZQA. The information that is released from the NZQA will be supplied to the
relevant selection committee(s) and UC authorised staff only, and will not be distributed further. I
understand that when the information is no longer required for this purpose, official University
procedure will be followed to dispose of my data.”
I understand that the information is held by the Scholarships Office, University of Canterbury,
Christchurch, and that I have the right to access and correct my personal information.
Legal Family Name
Legal Given
Name(s)
Date of Birth
NSN Number
Signature
Date
The Lyttelton Port Company Directors’ UC Scholarship – APPLICATION FORM 2016
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