Bachelor of Oral Health/Science Scholarship Application Form

Please fill out the below form to apply for the Bachelor of Oral Health/Science Scholarship.

Section A - APPLICANT DETAILS

Name

Title

Surname

First Given Name

Second Given Name

Date of Birth

DD/MM/YYYY

Home Address

Street

Town / Suburb

State / Territory

Postcode

Telephone Number

Mobile Number

E-Mail Address

Semester Address

Street

Town / Suburb

State / Territory

Postcode

Telephone Number

University E-mail Address

Citizenship

Are you an Australian citizen or permanent resident of Australia?

	Yes
	No

If yes - A certified copy of your birth certificate, naturalisation or other official documents such as passport will be asked for should you be selected to receive a Scholarship.

If no - You are not eligible to apply.

Aboriginal/Torres Strait Islander

Do you identify yourself as

	Aboriginal
	Torres Strait Islander

Other Information

Have you previously or are you currently receiving funding from another Scholarship or Grant Program?

	Yes
	No

If Yes - Name of Scholarship / Grant

Duration of Funding - From

Amount $

Section B - EDUCATION DETAILS

Current Tertiary Education

University currently enrolled at

Course name

Year Commenced

Length of Course

	Full Time
	Part Time

Anticipated Date of Completion

Section C – REFEREES

Please provide the name, address and contact phone number of two referees.

1. Referee

Full Name

Address

Contact Number

2. Referee

Full Name

Address

Contact Number

Section D – ADDITIONAL INFORMATION REQUIRED

The following additional information is required as part of your application for the Scholarship:

• An essay of 500 words outlining:

- Demonstrated understanding of the professional and personal issues involved in delivering public dental services and a commitment to bonded public dental service following graduation

- Written and interpersonal communication skills and ability to work effectively with a range of health professionals in a team or solitary environment

- An understanding of how a period of employment in a public dental service can contribute to a professional career path

- Demonstrated organisational skills, displaying initiative and self motivation to successfully complete the tertiary course in the minimum time period

• Curriculum Vitae

Attach Essay

Curriculum Vitae

If you are unable to attach any of the above documents, complete this application and forward to:

Administration Support Officer – Planning and Recruitment
Dental Health Services Victoria
PO Box 1273L
MELBOURNE VIC 3001

Note: Please mark "Bachelor of Oral Health/Science Scholarship Application".

Section E – DECLARATION

I have read and understood the Bachelor of Oral Health/Science Scholarship Guidelines.

I declare that the information supplied by me in this application is true and correct in every particular.

I authorise the Dental Health Services Victoria to seek details from the tertiary institution at which I am enrolled, including details of enrolment variations, academic record, examination results, attendance and any other matter pertaining to my eligibility to apply for a Bachelor of Oral Health/Science Scholarship.

I agree with the above statements

	Yes
	No

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Dental Health Services Victoria

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Bachelor of Oral Health/Science Scholarship Application Form