TEACHER EDUCATION SCHOLARSHIP PROGRAM 2011 APPLICATION Applicant s photograph Please provide a recent passport sized head-and-shoulders photograph of yourself 1 to 5 Year Scholarship Please attach Please read the Information Package before you complete this form. Please do not use staples to secure this document or your supporting documents Section 1: Personal Details: Title: Mr Mrs Ms Miss Other (specify): Family Name: First Given Name: Second Given Name: Former Family Name(s) (if applicable): Former First Name(s) (if applicable): Date of Birth: Country of Birth: Country of Citizenship: If you are not an Australian citizen, do you have permanent resident status? Yes No (Please supply supporting documentation.) Section 2: Contact Details: Email address: (Please ensure that your email account is current as this will be our main method of communication.) Address: Suburb, city or town: State: Postcode: Home telephone number: ( ) Mobile telephone number: Work telephone number: ( ) Mailing Address: Suburb, city or town: (Complete only if different from home address.) State: Postcode: 1 of 1
Section 3: Applicants who are Aboriginal people or Torres Strait Islanders: The NSW DET will award at least 80 scholarships to applicants who are Aboriginal people or Torres Strait Islanders. An Aboriginal person or a Torres Strait Islander is a person of Aboriginal descent or Torres Strait Islander descent who identifies as such and is accepted as such by the community in which he or she lives. Place an X in the box if you are an Aboriginal person or a Torres Strait Islander as defined above: Section 4: Academic Qualifications: (Please attach certified copies of your transcripts and academic results to date, if applicable.) Place an X in the box if you received any advanced standing on entry into your course: If you placed an X in the box above, please provide certified copies of transcripts of the results upon which the advanced standing was granted. Have you completed or are you currently completing an undergraduate degree? Yes No If yes, please specify: Degree: University: State: If still studying, duration of study remaining: 1 year 2 years 3 years 4 years 5 years Intended course of teacher training: Degree: University: State: Year to commence: Duration of study of intended course of teacher training: 1 year 2 years 3 years 4 years 5 years If no, please specify: From semester 1, 2011, your intended course of study (including teacher training): Degree: University: Duration of study of intended course, including teacher training: 1 year 2 years 3 years 4 years 5 years What will be your mode of study? (please tick one) Full time Part time 2 of 2
Section 5: Other Training or Qualifications: Please list any TAFE qualification, trade certificates or apprenticeships, HSC or equivalent, industry or employer sponsored training or other relevant training or qualification. Title Where/when obtained Section 6: Employment History: (If applicable) Period: From MM/YY to MM/YY Employer Summary of main duties (If space provided is insufficient, please attach an additional sheet) Section 7: Teaching Subject(s): Tick the subject(s) in which you will be qualified to teach at the completion of your training: (refer to the NSW Institute of Teachers undergraduate content requirements at http://www.nswteachers.nsw.edu.au/subject-content-requirements-abridged.html ) English with history with drama Mathematics Science must include physics or chemistry plus one other science: physics chemistry biology earth and environmental science Special Education (General) must be in combination with either a primary or secondary main teaching area: please specify name of main subject(s): Other: please specify name of subject(s): 3 of 3
Section 8: Commitment to teach: Please indicate below the geographic areas in which you agree to work as a teacher. This will be taken into account in assessing your application for a scholarship. I agree to teach in the following geographic areas: Anywhere in the State OR I do not wish to teach anywhere in the State, but I agree to teach in at least three of the following school areas (tick three or more boxes) PRIORITY AREAS Metropolitan areas (tick three or more boxes) Bankstown Fairfield Mount Druitt Blacktown Granville Campbelltown Liverpool AND/OR at least three of the following non-coastal rural areas Albury Deniliquin Tamworth Armidale Dubbo Wagga Wagga Bathurst Griffith Bourke Moree Broken Hill Orange NON PRIORITY AREAS You may also indicate a preference for the following areas but ONLY after metropolitan and/or non-coastal rural areas have been selected. This will be taken into account in assessing your application for a scholarship however the scholarship program purpose is to ensure a continuing supply of teachers for the priority areas listed above. Batemans Bay Newcastle St George Bondi Central Coast Northern Beaches Parramatta Sutherland Taree Clarence/Coffs Harbour Penrith Tweed Heads/Ballina Hornsby Port Jackson Windsor Lake Macquarie Port Macquarie Wollongong Lismore Queanbeyan Maitland Ryde Muswellbrook Shellharbour 4 of 4
Section 9: Supporting Statement: a) Please provide a short statement outlining your reasons for wanting to become a teacher in a NSW public school............... b) Please describe how your personal qualities, skills and interests (e.g. employment history, training courses, community involvement, sporting activities, performing or visual arts skills) will enhance your effectiveness as a teacher....... 5 of 5
Section 10: Declaration by Applicant: Place an X in the appropriate boxes 1. In respect of my criminal record, I have had: YES NO convictions for sexual or drug offences convictions for other offences child sexual assault charges dealt with under section 556a of the Crimes Act, 1990 charges that may not have been heard carrying a penalty of 12 months or more imprisonment. 2. In respect of my personal suitability, I have: a record of unsatisfactory service previous disciplinary action in another State/Territory/organisation been declared bankrupt within the past three years. 3. Are you aware of any illness, disability, or condition that may impact on your ability to perform the full range of duties of a teacher? 4. Are you under bond or similar obligation to any authority? Statement of understanding I have read the information provided and understand the terms of the 2011 Teacher Education Scholarship Program. I understand that, if offered a position in the 2011 Teacher Education Scholarship Program, I: 1. will be subject to a Probity Check and will complete a Consent to Employment Screening and a Prohibited Employment Declaration form; 2. will be obliged to execute a formal Deed of Agreement which includes obligations concerning: undertaking training and thereafter accepting an appointment at a particular position in an agreed location in NSW completing service for the three years (Period of Commitment) in a particular position as a permanent full-time teacher (Envisaged Appointment Area) repayment of financial assistance in certain circumstances such as: - this application containing misrepresentations - not completing training or recruitment requirements satisfactorily - not accepting, taking up or completing the Period of Commitment in the Envisaged Appointment. 3. have not and will not be seeking assistance from any other source which would or could hinder my ability to satisfy my obligations to the NSW Department of Education and Training as specified in the Deed of Agreement. I certify that the information I have provided on this form is accurate and complete. In applying, I acknowledge that personal information about me will be provided to the NSW Department of Education and Training and that in the interest of proper and prudent management of its sponsorship program, the NSW Department of Education and Training may liaise with and share information about me with other education authorities in both the public and private sectors. Applicant s signature: Date: Endorsement by parent or guardian if applicant is under the age of eighteen years 6 of 6
Parent s/guardian s signature: Date: Section 11: Endorsement by Referees (Note: referees must not be related to the applicant. You should nominate someone of high standing in the community who has known you for at least 12 months and who can confirm the accuracy of statements you are making on your application.) Referee 1: I certify that the statements in Section 10 made by the applicant are correct, to the best of my knowledge. Signature: Date: Name: Address: Home telephone number: ( ) Mobile telephone number: Work telephone number: ( ) Relationship to applicant: Referee 2: I certify that the statements in Section 10 made by the applicant are correct, to the best of my knowledge. Signature: Date: Name: Address: Home telephone number: ( ) Mobile telephone number: Work telephone number: ( ) Relationship to applicant: Privacy Notice The information provided by the applicant is being obtained for the purpose of the administration of the 2011 Teacher Education Scholarship Program by the NSW Department of Education and Training. It will be used by the NSW Department of Education and Training for consideration of the applicant s admission to the Program and the applicant s ongoing participation in the Program. Other persons and/or agencies that will or may be provided with this information are other education authorities in both the public and private sector. Reasons for the collection and disclosure of information are for the purposes of consideration of the applicant s application to participate in the Program, the applicant s participation in the Program and other purposes relevant to the proper and prudent management of the NSW Department of Education and Training s Scholarship Program. The information is provided as part of the applicant s applying voluntarily to participate in the Scholarship Program. The information will be stored securely. If the applicant does not provide all or any of this information then the application will not be considered by the NSW Department of Education and Training. The applicant may correct any personal information provided at any time by contacting the Scholarship Team on 1300 301 435 or email scholarships@det.nsw.edu.au. Office Use Only I have checked the applicant s supporting documentation and confirm that the responses justify/do not justify further consideration for a scholarship with the NSW Department of Education and Training. 7 of 7
Signature: Date: SCHOLARSHIP APPLICATION DOCUMENT CHECKLIST When submitting your completed Teacher Education Scholarship Program application, please ensure the following information and documents are included with your application. Documentation, as defined in the 100 point check, to support your identity. Refer to Appendix 1 of the information package, Identification Required by Applicants. Evidence of change of name for first and family name changes. Evidence of Australian citizenship, permanent residence, or visa permitting employment in Australia if not born in Australia. Passport size photograph glued only to the front page. Section 10 Declaration by Applicant (must be signed). Section 11 endorsement by referees (requires signatures by two people who are not relatives but know you sufficiently well to be able to certify that the statements made by you in section 10 are correct). Original Declaration and Employment Screening Consent form (signed and dated). Official transcripts of your initial qualification for each year of study (B.A., B.Sc., B.Ed., etc., if relevant). Official statement verifying satisfactory completion of your initial degree or other tertiary qualification (if applicable). ATAR advice (or interstate equivalent) and admission advice from your university admissions centre (submit once available). Evidence of subjects for which you are enrolled in semester 2, 2010 (if applicable). All documentation provided in accordance with the above checklist must be originals or certified copies of the original. A certified copy is a photocopy which has been declared by a Justice of the Peace, Solicitor or Department of Education and Training Officer to be an exact copy of the original. Any person who falsifies their record of academic and/or professional qualifications to gain employment may be dismissed and/or prosecuted. The closing date for applications is Friday 8 October 2010 Forward your application and supporting documents to: 2011 Teacher Education Scholarship Program Locked Bag 3020, Blacktown NSW 2148 Note: Late, incomplete or incorrectly completed applications may not be considered. Should you require any assistance please contact the Teacher Education Scholarship Information Line on 1300 301 435 or email scholarships@det.nsw.edu.au. 8 of 8
2011 Teacher Education Scholarship Program INFORMATION SURVEY Name (optional) Year of birth Sex Female Male What is your current occupation? I m studying at school I m enrolled at university I m at studying at TAFE I m working as a Other (please specify) What is the highest qualification you attained? Completing HSC this year HSC or equivalent TAFE certificate/diploma or equivalent Bachelor degree Postgraduate degree Other (please specify) Where do you live? Sydney metropolitan area Hunter/Central Coast Illawarra and South East New England North Coast Riverina Western NSW Other Australian state (please specify) How did you find out about our teaching scholarships? (You may tick more than one box) I visited the teach.nsw website I attended a teach.nsw presentation I went to a careers event/fair/expo (please specify) At school/tafe from my: careers adviser teacher principal other At university from: the careers service my lecturer the education faculty the Aboriginal support centre I saw a print advertisement in: SMH HSC Study Guide Koori Mail/National Indigenous Times I saw an advertisement online on: Facebook/Twitter New Scientist/Cosmos other (please specify) New Scientist/Cosmos Other (please specify) Vibe/National Indigenous Times Other (please specify) A friend/relative/significant person told me about the teaching scholarships. I chose to apply for a teacher education scholarship because: