Step 1 – Personal Details
Title:
First Name:
Last Name:
QTAC Number:
Date of Birth:
Mr
John
Citizen
140000000
Your QTAC number is the reference number which you
receive after you have lodged a QTAC application online. Your
QTAC number will begin with a ‘13’ (or a ‘12’ if you are a gap
year student who applied through QTAC in 2011).
01/01/1996
If you decide to accept a place at university will you be the first person in your immediate
family (father, mother, sisters and brothers) to attend university?
Yes / No
Do you identify as an Australian Aboriginal or Torres Strait Islander person? If you
answered yes, you will need to provide evidence of your Indigenous status.
Yes / No
Step 2 – Contact details
Australia
Address Line 1:
Suburb or Town:
State:
Postal Code:
University Drive
ST LUCIA
QLD
4072
International
Address Line 1:
Address Line 2:
Suburb or Town:
State:
Country:
Postal Code:
Home Phone:
Mobile Phone:
E-mail address:
(Note: International – for Australian citizens completing senior studies overseas)
Step 3 – Citizenship Details
Australian Citizen
Other
Step 4 – School Details
In what year did you / will complete year 12?
2012  2013
Are you completing the International Baccalaureate (IB)?
 Yes  No
Is your current school a public (i.e. State High School or private /
independent school?
 Public  Private
Please enter the full name and location of your secondary school.
Name:
Suburb or Town:
Post Code:
Country:
Step 5 – QTAC Information
The University of Queensland must be listed as either your 1st or 2nd QTAC preference to be
considered for an Academic Scholarship. The Selection Panel will be guided by your highest UQ
preference listed.
Please indicate your 1st and 2nd QTAC preferences below:
First Preference
Name of University:
Study Area:
Degree Name:
Second Preference
Name of University:
Study Area:
Degree Name:
Step 6 – Exceptional Academic Achievements
In years 11 - 12, have you been a medallist or state/national finalist or received a high distinction
in any state, national or international academic competition?
Please see the list below for examples.
Please do NOT include Participation, Credit, Distinction awards or School Subject awards.
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Australian Informatics Olympiad
Australian Mathematics Competition
Australian or International Space Design/Settlement Design Competitions
Bond University High Schools Mooting Competition
National / International Biology, Chemistry or Physics Olympiads or Tournaments
National Geographic Channel Australian Geography Competition
PWC Australian Economics and Business Studies Competition
QAMT or Macquarie Bank Future Problem Solving Competition
RACI Australian National Chemistry Quiz or Chemical Analysis Competition
Rio Tinto Big Science Competition
UNSW ICAS English, Maths or Science Competitions
UQ School of Economics QETA Student Economics Competition
Please list achievements and year of awards below: e.g. 2012 ICAS Maths-HD, 2013 RACI HD.
Step 7 – Leadership
In years 11 - 12, have you held any significant leadership positions and/or participated in any
leadership programs?
Please see the list below for examples.
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School captain, vice-captain or house captain
Music or debating team captain
Sporting team captain or coach
Student Representative Council, Interact Club office bearer or similar
president, secretary or treasurer)
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Defence Force cadet
Emu Gully Leadership Program
ADF Long Tan Leadership Teamwork Award
TIP Leader
Australian Student Leadership conference
Please list achievements and year of awards below: e.g. 2012 School Captain, 2013 ADF Long
Tan L’Ship.
Step 8 – Community Service
In years 11 - 12, have you undertaken any significant or ongoing community service activities? Please
see the list below for examples.
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Surf Life Saving club
Sony Foundation Children’s Holiday camp
Rosies Friends on Street Outreach program
Camp Quality
The Smith Family student2student reading program
Kokoda Challenge
Scouts Australia
Girl Guides Australia
Please list activities and year below: e.g. 2013 Girl Guides, 2012/13 Sony Children’s holiday camp
Step 9 – Awards received in Years 11- 12
In years 11 - 12, have you received any significant awards?
Please see the list below for examples.
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Duke Of Edinburgh (Gold Award only)
Lions Youth Of The Year - State or National finalists only
Order Of Australia Association Student Citizenship Award
Pierre De Coubertin Award
Quest Newspapers Young Star Awards - Category Winner
Caltex All-Rounder
Please list awards and year received below: e.g. 2012/13 Caltex All-rounder
Step 10 – Major Youth Forums and Conferences
In years 11 - 12, have you attended any of the following forums or conferences? Please see the list
below for examples.
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QLD or National Youth Aerospace Forum
National Mathematics Summer School
National Schools Constitutional Convention
National Youth Science Forum
United Nations Youth Conference
Engineering Links Camp
UQ Young Scholars Program
Global Young Leaders Conference
Please list forums or conferences and year attended below: e.g. 2013 UN Youth Conference,
National Youth Science
Step 11 –Undergraduate Medicine and Health Science Admissions Test (UMAT)
Have you completed the Undergraduate Medicine and Health Sciences Admission Te
(UMAT)?
Yes / No
If you ticked yes, please indicate your results for each component. You will be
required to provide evidence.
Section 1:
Section 2:
Section 3:
Total UMAT Score:
Step 12 –UQ Residential College
Have you applied for a place at one of The University of Queensland's
Residential Colleges?
Yes / No
Name of College:
Step 13 – Educational Disadvantage
UQ reserves a number of Academic Scholarships for high-achieving students
who have experienced educational disadvantage during their senior studies.
Please tick either or both of the following if they apply to you.
Significant financial hardship
Geographic isolation (i.e. living and studying in an isolated area)
If you ticked either of the above, please describe in your Personal
Statement how your circumstances have affected you and influenced your
ability to achieve academically in years 11 and 12. You will also need to
provide evidence of your circumstances.
Examples of evidence that should be provided:
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Significant financial hardship: current Centrelink statements (e.g.,
Youth Allowance, FTB etc), parents' most recent ATO (income
tax) assessment notices, any other documentation that is relevant to
your financial circumstances.
Geographic isolation: school reports showing name and location of
high school.
Step 14 – Personal Statement
Please provide a Personal Statement of no more than 300 words in support
of your application. This is an opportunity for you to tell us about your future
study and career aspirations including any educational disadvantage if
indicated in step 13. Your Personal Statement should be attached to the
documentation you provide to the University as part of the application
process.
Step 15 – Applicant Declaration
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I have read the UQ Academic Scholarship Guidelines.
I understand that the scholarship selection process is very competitive
and not all applicants who meet the eligibility criteria will be awarded
a scholarship.
I understand that if I am awarded a named or industry-sponsored
Academic Scholarship, that this award will be conditional on enrolling,
and remaining enrolled in the program stipulated in my scholarship
offer.
I give permission for my Year 12 results and relevant information to be
provided to UQ through QTAC.
If awarded a UQ Academic Scholarship, I give permission for my name,
contact and scholarship details to be released to university faculties
and divisions, residential colleges and my year 12 high school.
I declare that the information supplied on this form is complete and
correct to the best of my knowledge. If any information provided is
found to be false or misleading, I accept that the University may cancel
or withdraw any scholarship awarded to me and require me to repay
any scholarship funds received.
Yes / No
Date: