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Dorothy L Newman Scholarship Application form for study
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If you need assistance in filling out your form, please contact your local MS Society or MSNZ on 0800 MS LINE (67 5463) or info@msnz.org.nz
Documents you will need to submit with this form to info@msnz.org.nz
- Copy of your current CV
- Confirmation of your diagnosis
- Course Information
Details of the Applicant
Persons name
*
First name
Last name
Email address
*
Cell phone
*
Other phone
Address
*
Address line 1
Address line 2
Address line 3
Address line 4
Town/Suburb
City
Postcode/Zip
Are you connected to an MS Regional Society?
*
Yes
No
Please select the Regional Society you are connected to
Northland Multiple Sclerosis Society Incorporated
Multiple Sclerosis Auckland Incorporated
MS Waikato Trust
Bay of Plenty Multiple Sclerosis Society Incorporated
Rotorua and District Multiple Sclerosis Society Incorporated
Hawke's Bay Multiple Sclerosis Society Incorporated
The Gisborne and East Coast Multiple Sclerosis Society Inc
Taranaki Multiple Sclerosis Society Incorporated
Wanganui Multiple Sclerosis Society Incorporated
The Manawatu Multiple Sclerosis Society Incorporated
The Wellington Multiple Sclerosis Society Incorporated
Nelson Multiple Sclerosis Society Incorporated
Marlborough Multiple Sclerosis Society Incorporated
MS West Coast Incorporated
Multiple Sclerosis & Parkinson's Canterbury Charitable Trust
South Canterbury Multiple Sclerosis Society Incorporated
Southland Multiple Sclerosis Society Incorporated
Otago Multiple Sclerosis Society Incorporated
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Dorothy L Newman Scholarship Application form for study
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As this award is for people who have been diagnosed with Multiple sclerosis we need to confirm your diagnosis.
Have you been formally diagnosed with Multiple Sclerosis?
Yes (continue to the next question)
No (Sorry but this scholarship is only for those who have a formal diagnosis of MS)
We will need Authentication from Regional MS Society and/or Doctor for your diagnosis along with a letter for support. At the end of this form we will send you an email to remind you to send this in.
Details of person who will authenticate your diagnosis of MS
First and last name
*
Organisation Name
*
Phone number
*
Address
Postcode
Referee
Please include the name and contact details of a referee who is willing to be contacted in support of your application.
First and Last Name
*
Day time Phone Number
*
Email Address
*
Home address
Relationship to applicant?
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Dorothy L Newman Scholarship Application form for study
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Study details
Intended course of study?
*
University /Training Institution
*
Why did you choose this programme and provider?
*
Total cost of course
Amount applying for
If Scholarship funds cannot cover your full request, are you able to fund the remainder from other sources? Please give details.
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Dorothy L Newman Scholarship Application form for study
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Tell us more about you.
Tell us about yourself (who are you, what are your interests and hobbies, what is important to you?)
Tell us about your MS and how it impacts your life?
How has MS impacted your career?
What are your long-term career goals?
Can you identify any limitations to either your chosen course of study or long-term career prospects?
What would this scholarship mean to you, and why do you think you deserve it?
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Dorothy L Newman Scholarship Application form for study
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Declaration
I confirm that the information contained in this application is true and correct.
I am aware and accept that the personal information collected about me in connection with this application will be used by the Selection Panel for the purposes of assessing this application only.
I agree that if I am successful in my application, I will be required to give permission for my photo and information relating to the application (i.e. how I intend to use my qualification) to be used for publicity purposes.
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Please check the highlighted fields
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