Discretionary Award. Application form

Transcription

1 Application form Please complete all the boxes and return this form to: McTimoney Trust, 26 Wake Green Road, Moseley, Birmingham B13 9PA It is advised that you retain a copy of your application form for your records Your details: First name/initial(s): Surname: Full home address: Postcode: Phone: To be signed by all applicants: I believe the information I have given on this form is correct. I understand that if I give false information my application will be cancelled and further action may be taken by the Trust. I undertake to inform the Trust of any change in circumstance that may affect my award. I undertake to repay on demand any overpayments of my bursary that may arise due to miscalculation, re-evaluation of eligibility, unsatisfactory attendance or progress, or any other reason. I understand and give permission for the McTimoney Trust to contact the McTimoney College of Chiropractic to verify information submitted with this application. I have read, understood and agree with the terms and conditions above: Signature: Date: DD / MM / YYYY Personal data The personal data which has been supplied with the bursary application is protected under the 1988 Data Protection Act and will: Be used only in the processing of this application. Not be disclosed to a third party other than those named on the application without your explicit consent, except in the prevention of fraud. Be destroyed after 6 years. Be used in compliance with statutory obligations for the submission of data and statistical information to government agencies. page 1 of 7

2 Can you demonstrate unplanned financial need? If Yes then please continue with this application. Yes No If No, you are not able to evidence financial need, then you will not be eligible to apply for an award from the McTimoney Trust. For further information please contact Which course are you studying? MChiro 5FTE MChiro 4FT Where are you studying? Abingdon Manchester Course Dates - When did you start the course and when do you expect to finish? Start date Date: DD / MM / YYYY Finish date Date: DD / MM / YYYY Please tick your training year Date commenced at McTimoney College of Chiropractic Date: DD / MM / YYYY Are you a member of the McTimoney Chiropractic Association? Yes No Financial and supporting information provided with my application: Monthly budget Latest bank statement Last payslip Benefit notice HMRC P60 HMRC Tax Return Student finance award letter Exam results Tutor s report Other (please specify): page 2 of 7

3 If applying for more than one award, please complete a separate application form for each award. You will need to provide evidence for each application even if your financial information is the same. How did you hear about the Bursary Scheme? Trust e-flyer Posters in College College announcement College staff MCA e-newsletter MCA mailing Trust website Recommendation Other (please specify): page 3 of 7

4 Please complete all the fields in this form. This information will help the panel to assess your circumstances. INCOME - Please provide a summary of your annual current income Do you/will you receive any further funding for this course from other sources? If Yes, give details, including amounts and whether they are loans or grants? Yes No Your Income Sources Your net monthly income Interest/dividends: Your partner s income sources Your partner s net monthly income Interest/dividends: Student-related loans/grants: Student-related loans/grants: Benefits: Benefits: Total Total savings including shares Total Total savings including shares JOINT TOTAL INCOME JOINT SAVINGS page 4 of 7

5 HOUSEHOLD SIZE (how many dependants, adults and children, are in the household?) EXPENDITURE - Please provide a summary of your annual current expenditure McTimoney College of Chiropractic course fees Other educational related fees Credit commitments Mortgage payment Mortgage payments and other residential properties Student loan repayments Monthly loan & HP payments Monthly credit card and overdraft payments Total credit commitments Housing Ground rent/service charge House buildings/contents insurance Council tax Electric/Gas/Fuel/Water Telephone (including mobiles) TV licence/subscriptions Other Total housing expenditure Personal expenditure Maintenance payments Child care costs/school fees Car/Travel expenses Car/Travel expenses to/from College Life assurance premiums/endowment policies Food/Living expenses Other (including entertainment and holidays) Total personal expenditure TOTAL MONTHLY EXPENDITURE RESIDUAL AFTER MONTHLY EXPENDITURE page 5 of 7

6 Any other information regarding income and/or debt that I wish the Awards Panel to consider: Please explain below why you feel you should be considered for this award. Please limit your personal statement to a maximum of 500 words. page 6 of 7

7 Equal opportunities monitoring The Trust is committed to social justice and equality. We also aim to meet the needs of a wide range of beneficiaries who need the Trust s support. We work within the Equality Act 2010 and have an Equality and Diversity Policy. We hope you will help us check that we are meeting our aims. We will use the information to check to see if we are providing equality of opportunity. However, you do not have to provide this information if you do not wish to. The information you provide here will not be seen by the people undertaking the assessment of the Awards. My current age is Gender Male Female Or I would describe myself as... Disability - I have the following disabilities which limit my everyday activity Nationality - Please state which country you normally reside in (for UK, please state England, Northern Ireland, Scotland or Wales: Race - I would describe my race as being, e.g. White / Asian / Black / Afro-Caribbean / Other / Prefer not to say: Religion or cultural beliefs - I would describe my religion or cultural beliefs as, e.g. Christian / Muslim / Jewish / Sikh / no religion / prefer not to say: Sexual orientation - I would describe myself as Heterosexual / Homosexual / Gay / Lesbian / Bisexual / Prefer not to say: Have you accessed the CAB financial Healthcheck? Yes No page 7 of 7