Mental Health Justice Health Alcohol and Drug Services
Postgraduate Scholarship Mental Health Nursing
Application Form – New Studies
For new studies commencing in 2015, or for continuation of a course for which a scholarship
has not previously been awarded:
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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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 yes, do not continue. Please complete the application form titled “Mental Health
Justice Health Alcohol and Drug Services Postgraduate Scholarship Mental Health Nursing Application
Form - Continuing Studies”.
If your answer is no, 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.
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 Scholarship Mental Health Nursing Program with
Mental Health Justice Health 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: Post Graduate Diploma (Mental Health)__________________________________
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 the University of Canberra?
YES / NO
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Criterion 5 – Details of financial assistance for 2014
Postgraduate Scholarships Mental Health Nursing Scheme is 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 subjects 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 after census day cut off, you
may be liable for the cost of those units and 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 name and address you used in your 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 of 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 current 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 2015 Postgraduate Scholarship Mental Health Nursing Scheme Guidelines and
Information and agree to abide by the conditions for successful applicants. I understand that
scholarships are allocated at the discretion of the 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 2606
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