ANU Enterprise ACCESS UNDERGRADUATE SCHOLARSHIP
FOR A STUDENT WITH A DISABILITY

APPLICATION FORM

Applications must be lodged with:
Attention: Manager,
Disability Services Centre,
Students Facilities Bldg (17A),
The Australian National University, CANBERRA, ACT 0200

Or submitted by email to Disability.Adviser@anu.edu.au

Applications close on 9 March 2009.
Receipt by the University of your application form will only be acknowledged if you send a stamped, self-addressed envelope.

Before you complete this form you should read the accompanying Award Conditions.
Please note the successful applicant must not have completed any previous tertiary degree or tertiary diploma.

PERSONAL DETAILS

Name: _________________________________________________________________________

Please tick appropriate box Male Female

Postal address in January/February (include the postcode please): ______________________________

_________________________________________________________ Postcode: ____________

Telephone ( ___ ) ___________________ Mobile: _______________________________

January/February telephone number: ( ___ ) ______________________________

Are you an Australian citizen? YES NO

If not, do you hold permanent resident status? YES NO

STUDY DETAILS

Are you a current ANU Student? YES NO

Intended or Current Program of Study at the ANU (e.g. B. Arts):

__________________________________________________________

SCHOOL HISTORY
Name and address of Secondary School (including postcode):

____________________________________________________________________________

________________________________________________________ Postcode: ____________

University Admissions Centre Application Number: ______________________

Final year at school: ___________________________________

Name of secondary qualification (eg Year 12, HSC, Senior): _________________________

Universities Admission Index (UAI):

OR Post Secondary Academic Grade Average:

DISABILITY DETAILS

In order to be eligible for this scholarship you need to provide proof of your permanent disability from a medical professional. This documentation needs to be attached to this application.

Please describe your disability (or disabilities) and the effects on your studies:

______________________________________________________________________________

______________________________________________________________________________

FINANCIAL DETAILS

List any scholarships, bursaries or government allowances that youn will receive in 2008, or that you have applied for:

_____________________________________________________________________________

______________________________________________________________________________

Please provide details of your current financial situation, and how this scholarship would assist you to be successful in your studies:

_____________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________

______________________________________________________________________________

INFORMATION ON APPLICATION FOR ADMISSION TO THE AUSTRALIAN NATIONAL UNIVERSITY

Do not forget that students not currently enrolled at The ANU must also apply for admission to the Australian National University. You must apply through the Universities Admissions Centre (NSW & ACT), Locked Bag 112, Silverwater NSW 2128. (Quad 2, Australia Centre, 8 Parkview Drive, Homebush Bay, NSW) Telephone (02) 9752 0200. Application information for school leavers is available from their schools.

Applications should be lodged with UAC by 28 September 2007; those lodged after that date attract an increasing late fee.
Applications are not accepted by UAC after midnight 1 February 2008. (Please refer to UAC 2007 Guide for Applications and documentation submitted after 7 December 2007).

You are not required to list your ANU course choice as first preference to be considered for a scholarship but you must select a course at ANU as one of your six preferences to be considered for an ANU ANU Enterprise Access Scholarship. It is not possible to defer this scholarship.

• If you wish the committee to take into account financial hardship, please enclose a letter setting out relevant details.

• All information will be held in confidence and only seen by the committee members responsible for choosing the awardee. If requested, the committee will return original documents.

Signature:................................................................ Date:...............................