2016 Bernie Kilgariff Memorial Scholarship Application
This scholarship is open to students who completed secondary schooling in Alice Springs,
completed Year 12 in 2014 or 2015 and who is undertaking tertiary studies in a medical/health
related field in 2016.
Applications must be received by 4.30 pm on Friday 11 March 2016.
Please check your eligibility against the Northern Territory Government Bernie Kilgariff
Memorial Scholarship 2016 Terms and Conditions before completing this form.
Bernie Kilgariff Memorial Scholarship 2016 application
Personal details
Family name
Date of birth
Given name(s)
Male
Female
Residential address
State
Post code
Postal address
State
Post code
Home phone
Mobile phone
Email address
Phone contact
during term
Contact person (for example, parent, guardian, relative) to receive requests for information
regarding this scholarship
Name
Relationship
Residential address
State
Post code
Home phone
Work phone
Email address
Mobile phone
Length of residency in Alice Springs?
years
Are you an Australian Citizen? If ‘No’, proof of residency
Yes
No
Are you Aboriginal descent?
Yes
No
Are you of Torres Strait Islander descent?
Yes
No
Are you from a non-English speaking background?
Yes
No
Yes
No
If ‘Yes’, what is your first language spoken at home?
Do you have a disability or impairment?
If ‘Yes’, please briefly describe
Department of Business
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Bernie Kilgariff Memorial Scholarship 2016 Application
Bernie Kilgariff Memorial Scholarship 2016 application
Education information - a copy of your results must be attached
What high school did you most recently attend?
What year did you complete Year 12?
2014
2015
Northern Territory Board of Studies Higher Education
Entrance Information Australian Tertiary Admission Rank
(ATAR) or equivalent score
Other assistance
Have you applied for another scholarship or bursary, traineeship,
apprenticeship or are you receiving study assistance from any other
source? If ‘Yes’, please advise details:
Yes
No
Source / details
Will the other assistance be paid directly to you or to the university for course fees or
accommodation costs?
Amount ($ per annum)
When will you be notified that your application for other assistance has
been successful or not?
University enrolment - a copy of the course enrolment must be attached
Name of university
Address
Course name
Course major
Course code
Length of full-time course
Application check list - your application will not be assessed unless the following information
is attached (please do not send original documents)
Proof that you live in Alice Springs (for example, copy of driver’s license or a bank
statement with residential address).
Proof of Australian citizenship or residency (birth certificate, passport or immigration
document).
Proof that you completed your secondary schooling in Alice Springs and the NTCET or
equivalent.
Proof of 2014 or 2015 ATAR.
Confirmation of university enrolment which shows the units you are enrolled in for
semester 1, 2016, your name and the name of the university.
If you are studying interstate, evidence that the core program is not available to study in
the Northern Territory.
Personal Statement: Outline why you have chosen your field of study. Outline how the
scholarship will assist you in completing your studies and if studying interstate, why
studies cannot be undertaken in the Northern Territory.
Department of Business
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Bernie Kilgariff Memorial Scholarship 2016 Application
Bernie Kilgariff Memorial Scholarship 2016 application
Personal statement
Name
Outline why you have chosen your field of study and career aspirations. Outline how the
scholarship will assist you with completing your studies and, if studying interstate, why studies
cannot be undertaken in the Northern Territory.
Declaration
I completed my secondary education Alice Springs in 2014 or 2015.
I have read and understand the Northern Territory Government Bernie Kilgariff Memorial
Scholarship 2016 Terms and Conditions.
I certify that my application is within the terms and conditions. I intend to meet the terms
and conditions if granted a scholarship. I understand that a breach of the terms and
conditions could lead to withdrawal of the scholarship and in certain circumstances
recovery of monies paid under the scholarship.
I declare that the information contained in this application and attachments is, to the best
of my knowledge, true and correct.
Signature
Date
For further information or assistance with completion of this form email scholarships@nt.gov.au
or telephone the Scholarships Administrator on (08) 8935 7706.
If the Scholarships Administrator requests further information to support your application, a
timeframe will be advised for the information to be received. If the information is not received
within the timeframe the application will be deemed ineligible.
Email your application and supporting documents to scholarships@nt.gov.au
Applications close at 4.30 pm on Friday 11 March 2016.
Late applications will not be accepted.
The Northern Territory Government is collecting this information for the administration of Northern Territory
Government Scholarships. Only authorised officers have access to this information. Your personal information will not
be disclosed to any other third party without your consent, unless authorised or required by law, in accordance with
the Information Privacy Principles.
Department of Business
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