Application Form

Personal and Contact

Title *

First Name *

Surname *

Gender *

Date of Birth

Daytime Contact Number *

Mobile *

Email Address *

Postal Address *

Residentail Address (if different)

Eligibility Criteria

Are you an Australian citizen or have you been granted Australian Permanent Resident Status? *

Are you of Aboriginal or Torres Strait Islander descent? *

Are you applying for entry or currently enrolled fulltime in a Certificate III in Community Pharmacy? *

Course Details

Name of Nationally Accredited training provider in which you are enrolled or intend to enrol *

Total length of course *

Year of study you are undertaking this year *

Scholarship Awareness

How did you become aware of the Scholarship ? *

Please describe how the scholarship will support you with your studies? *

Declaration

I understand that the following are conditions of any scholarship that I may be offered and that I may lose my entitlements under that scholarship if I do not at all times comply with every such condition:

Applicants must complete a Statutory Declaration if awarded a conditional scholarship offer declaring that all the information provided in the application form is accurate and complete. Penalties apply for making a false statement in a Statutory Declaration.
Applicants who are awarded a conditional scholarship will be required to supply range documentary evidence to verify their eligibility for the scholarship
The information on this form is collected for the purpose of assessing scholarship eligibility and selection.
If successful, I must participate in the Mentor Program and have ongoing contact, on at least a quarterly basis, with the Mentor.
If successful I must provide all verification documents as requested by The Pharmacy Guild of Australia for the life of the scholarship.

I agree

to participate in the Scholarship Initiative as outlined in the Initiative Guidelines and the Terms and Conditions.
to my details (excluding personal status information) being published by Symbion and the Pharmacy Guild of Australia in promotional material.
to advise the Pharmacy Guild of Australia immediately of any change in my circumstances.
to sign a Scholarship Agreement with The Pharmacy Guild of Australia if my application is successful.
to provide information and verification documents as requested by The Pharmacy Guild of Australia.

I understand and agree to obide by the conditions stated above *

Yes

Full Name