Mental Health, Justice Health & Alcohol and Drug Services
Postgraduate Scholarship Mental Health Nursing
Application Form – Continuing Studies
For recipients of 2014 scholarships whose studies are continuing into 2015
Applicants are encouraged to submit applications electronically to:
NMScholarships@act.gov.au
If electronic submission is not possible, applications (marked CONFIDENTIAL) may be sent by
mail to:
Professional Development Coordinator
Nursing & Midwifery Office
Level 3, Building 6
Canberra Hospital
PO Box 11
Woden ACT 2601
GPO Box 825 Canberra ACT 2601 | phone: 132281 | www.act.gov.au
Are you seeking additional funding to continue studies in the same course for which
you were awarded a scholarship in 2014? YES / NO
If your answer is No and you were not a recipient of a scholarship in 2014, are commencing a new course
in 2015, or are continuing a course for which you have not previously been awarded a scholarship, do not
continue. Please complete the “Mental Health, Justice Health & Alcohol and Drug Services Postgraduate
Scholarship Mental Health Nursing Application Form - New Studies”.
If your answer is yes please continue.
Criterion 1 - Applicant details
Title:
Family Name:
Given Name:
Home Contact Details
Postal Address:
Telephone:
Mobile:
Email:
Work Contact Details
Postal Address:
Telephone:
Mobile:
Email:
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Are you an Australian citizen? YES / NO
OR
Are you a permanent resident of Australia? YES / NO (If Yes please provide evidence)
Please note – If you are not an Australian citizen or permanent resident you are not eligible for a Mental
Health, Justice Health & Alcohol and Drug Services Postgraduate Scholarship Mental Health Nursing.
Criterion 2 – Registration
Do you have a current unconditional practicing certificate? YES / NO
Australian Health Practitioner Regulation Agency (AHPRA) Registration Number: ___________________
Criterion 3 – Details of Acceptance to Program
Have you been offered a place in the 2015 Postgraduate Diploma (Mental Health) Nursing Program at the
University of Canberra with Mental Health, Justice Health and Alcohol and Drug Services (MHJHADS)? YES /
NO
Have you attached a copy of your letter of offer from MHJHADS? YES / NO
Commencement date:_ _________________________________________________________________
Anticipated Completion date: ____________________________________________________________
Post qualification nursing/ midwifery experience (years): ______________________________________
Employment status (permanent/ Calvary transfer/ fixed term contract):_ _________________________
Employment hours (full-time/ part-time): ___________________________________________________
Have you attached a copy of your Curriculum Vitae/Resume? YES / NO
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Criterion 4 – Details of Course
Name of Course: _Postgraduate Diploma (Mental Health) Nursing__________________________
Name of Tertiary Institution: University of Canberra______________________________________
List 2014 units by semester and name:
Have you attached a copy of your letter of acceptance into this course from University of Canberra?
YES / NO
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Criterion 5 – Details of financial assistance for 2014
Postgraduate Scholarship Mental Health Nursing fees are paid directly to the University of Canberra
on your behalf. Initial enrolments in all units will be paid for by this scholarship. Payment of future
enrolments in previously failed units will be the responsibility of the scholarship recipient.
Scholarship funding does not carry across future years.
Please note: If you decide to withdraw from a unit/units of study and do so after the census day
cut off you may be liable for the cost of those units enrolled in for that semester and may be
required to pay ACT Health all monies outlaid on your behalf.
Have you received a nursing scholarship or funding from ACT Health in the past?
If yes,
(a) Which year?
Please provide the name and address you used in previous application
Name:
Address:
(b) Have you applied for a scholarship or professional development funding from
another source? Eg. Employer, Nursing and Midwifery Board, professional body? YES /
NO
If yes,
Name of source:
Amount sought:
Have you been successful?
$
Yes / No
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Check list for submission of Postgraduate Scholarship Mental Health Nursing Scheme application

Completed application form

Evidence of permanent Australian residency (if applicable)

Evidence current unconditional practicing certificate

Copy of letter of acceptance from MHJHADS into program

Copy of the letter of offer/ documentary evidence of acceptance into course
from University of Canberra

Copy of Payslip

Completed FBT Form
Please Note: Incomplete applications will not be considered. It is the responsibility of the applicant
to ensure all documentation is attached.
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Declaration
To the best of my knowledge the information I have provided is true and correct.
I have read the Postgraduate Scholarship Mental Health Nursing Guidelines and Information and
agree to abide by the conditions for successful applicants. I understand that scholarships are
allocated at the discretion of ACT Health and that the decision of the Department is final.
Applicant name:_________________________________________________________________
Signature: ______________________________________________________________________
(Sent from work email, serves as an electronic signature)
Date: __________________________________________________________________________
Applicants are encouraged to submit applications electronically to:
NMScholarships@act.gov.au
If electronic submission is not possible, applications (marked CONFIDENTIAL) may be sent by
mail to:
Professional Development Coordinator
Nursing & Midwifery Office
Level 3, Building 6
Canberra Hospital
PO Box 11
Woden ACT 2601
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