2010 S CH O L A R S H I P Where you grew up I N FORM At I O N & APPLICAtION 1. For each phase of your life name the town (or nearest town) where you spent the majority of your time. If not in NSW, please also nominate the State. If you lived overseas, also list the country and give the approximate population of the relevant towns. Early childhood (< 5 years of age) Years Primary schooling (5 –12 years of age) Years Secondary schooling (13–16 years of age) Years Senior secondary (17 & 18 years of age) For enquiries regarding the Cotton Industry Years Medical Scholarship, please contact Marie Kelliher – 2. If you grew up in a metropolitan area, did you regularly visit non metropolitan areas prior to going Tel 02 8337 8100 to university? Fax 02 8337 8110 Not applicable No Yes Email email@example.com 3. Has your spouse or partner ever lived in a Completed applications can be emailed, non metropolitan area? faxed or posted to: Not applicable No Yes Marie Kelliher If yes, please indicate the number of years Project Officer – Education & Training NSW Rural Doctors Network NSW Rural Doctors Network PO Box 1111 PO Box 1111 Mascot NSW 1460 To complete your application Mascot NSW 1460 Tel 02 8337 8100 Please attach the following information: Fax 02 8337 8110 a) Proof of enrolment for 2010 Applications must be received by Email firstname.lastname@example.org b) Resume 5pm Friday 9 April 2010 c) A short essay answering the following question: Hard copy applications should NOT be stapled. ‘What do you hope to achieve by holding the 2010 Cotton Industry Medical Scholarship?’ www.nswrdn.com.au Cotton Industry Medical Scholarship (300 word minimum – 500 word maximum) RDN4513 What is the Scholarship? How are payments made? Who is eligible? 2010 Cotton Industry Medical The Scholarship will provide a student studying The selected student will receive financial support Applicants must be an Australian or New Zealand Scholarship Application Form at an Australian Medical School with $5,000 per in three payments. Payments are made prior citizen or a permanent resident of Australia and be Family name ___________________________________ year for three years to assist with costs associated to placements and on completion of the two studying medicine at an Australian medical school. Given name(s) _________________________________ with their studies. week placement period following submission Applicants must be enrolled in: Gender _______________________________________ of an evaluation. Students not honouring their In return, the student is required to spend two • 2nd year of a post graduate medical degree; Date of birth _______________________ Age _______ commitment to undertake rural placements will be weeks on a rural placement per year in a NSW required to pay back all money granted to them. • 3rd year of a five year medical degree; or Student number ________________________________ cotton growing region during their university • 4th year of a six year medical degree. University _____________________________________ holidays. Placement programs reflect the enjoyable aspects of rural health practice. AREA MAP Applicants must demonstrate: University year _________________________________ • an understanding of the realities of rural medical term address __________________________________ The scholarship is funded and supported by the Gwydir Valley Cotton Growers Association. It is practice (both positive and negative) ______________________________________________ administered by the NSW Rural Doctors Network. • the motivation to undertake placements in a Mobile ________________________________________ cotton growing area term telephone ________________________________ • an understanding of the cotton industry and/or be Permanent address _____________________________ from a cotton growing area ______________________________________________ ______________________________________________ How to apply? Permanent telephone ___________________________ Complete the attached registration form and return. Email _________________________________________ Additional registration forms and selection criteria can Are you an Australian or New Zealand citizen or be found at www.nswrdn.com.au permanent resident of Australia? Yes No Are you an Aboriginal or torres Strait Islander? Yes No Signature _____________________________________ Date__________________________________________ The Cotton Industry Medical Scholarship provides for a rural medical placement in the Moree cotton growing area.
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