CODE NO.

PRELIMINARY APPLICATION FORM FOR AUSTRALIA NEW ZEALAND AND SAMOA GOVERNMENTS' OVERSEAS SCHOLARSHIPS 2013 INTAKE
PLEASE PRINT CLEARLY 1. PERSONAL DETAILS
1)

First Name: Gender:

Suieni
Female Male

Surname:

Ah Kee Date of Birth: 31/05/1981 31 years 2)

Applicant's Country of Birth: Marital Status: Married

Samoa
Single

Age on 1 Jan 2013

3)

4) Parent's Names: Fathers Full Name:

Tanuvasa Tafeaga Ah Kee

Date of Birth Date of Birth

Mothers Full Name:
4) 6)

Ulufale Tafeaga Ah Kee Lalomalava, Savaii Where are your parents residing?
Contact Details(Phone):

11/11/1941 06/10/1940

Mobile: 685- ____________________Home: 685- ____________________Work: 685- ____________________

7776114 24881 s_ahkee04@yahoo.com 24914 Fax: 685- ____________________ Address: ______________________________________________ Email
Please answer all the following questions (tick one box only)

2. PERMANENT RESIDENCE/CITIZENSHIP DETAILS
7)

Are you a Samoan Citizen? If no you are not eligible Are you applying for or do you hold New Zealand/Australian permanent residence? List all countries you hold citizenship and/or Permanent Residence Status Citizenship

Yes

No

8) 9)

Yes

No Permanent residence

Samoan

Samoa

10) List all countries your parents hold Citizenship

Citizenship

Permanent residence

or Permanent Resident Status

Samoan
Yes

Samoa
No Permanent Residence

11) Are you married or in a defacto relationship, with a person who holds residency or

citizenship of another country other than Samoa? Citizenship If YES, clearly specify what citizenship and /or permanent 12) residence he/she holds: 3. CURRENT EMPLOYMENT DETAILS
13) Are you employed? 14) 15) 16)

If no you are not eligble

Yes

No

Assistant Administration Officer Occupation Samoa Land Corporation Limited Name of employer 10 How long have you been employed at your current occupation? Years
4. PREVIOUS EMPLOYMENT DETAILS Yes Years No months

17) Were you employed previously prior to your current occupation?

If yes: How long were you employed at your previous occupation? Name of previous employer:
18) Occupation : 19) Did you work more than 5 years prior to your previous occupation?

Yes

No

5. STUDY PROGRAMME DETAILS
20) Please state your proposed field/area of study?

Human Resource Practitioners

21) What is the level of studies/qualification you wish to pursue? (Please tick one only)

Certificate Masters
22) Mode of Study

Diploma PHD

Degree (ALA) Australia Leadership Awards ONLY

PostGrad Diploma

AusAID /SSS

Full time (more than 1 year) Distance & Flexible Learning (more than 1 year)

23) Are you currently studying full time/part time under a scholarship scheme?

Yes

No

If yes you are not eligible
24)

Have you held a Scholarship for tertiary studies locally/overseas or via Distance Flexible Learning (DFL)? Terminated Completed

Yes Month/Year of Termination Month/Year of Completion / /

No

25)

If yes and you were terminated name the scholarship award you were terminated from. Yes
(If Yes , answer the next question)

26) Do you hold any tertiary qualifications?

No
(If No, disregard the next question)

27) List your most current qualifications and when obtained

Sponsor: Which years did you study? Qualification Received: Institution:

Self Funding 2000 - 2001 Samoa Polytechnic

Dip. in Secretarial Studies

Sponsor: Which years did you study? Qualification Received: Institution: Yes No

eg/ 2001-2005

28) Are you currently under any Bond arrangement?: 29) If yes, please give details of the bonding arrangement 30) Where did you hear about these scholaships?

Online
(Indicate specific source of information eg: Samoa Oberserver, Online, Word of mouth) answer each question will render the application invalid

Failure

to

I declare that the information contained on this form and all my correspondence is correct in every detail. I understand that the Governments of Australia, New Zealand and Samoa reserve the right to confirm the accuracy of the information in this application and any subsequent applications with the Governments of Australia, New Zealand and Samoa or any other authorities and that incorrect statements may result in me being declared ineligible for a Scholarship.
Signed: Date:

Completed preliminary application forms are to be delivered ONLY to the Ministry of Foreign Affairs and Trade, Scholarship Office up and until 4.30pm on Tuesday 27th March 2012. A list of eligible applicants will be posted at the MFAT foyer/website [www.mfat.gov.ws] as from Friday 06th April 2012. ONLY those listed are required to download Common Application Forms either from the MFAT website or uplifted from the MFAT Reception Level3 Government Building.
ALL enquiries to: MFAT from Monday - Fridays 10-12pm & 2:30 - 4:00 pm Phone # 21171 ext 128, 114,129,106,115 or 22856

LATE & INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED

NO ATTACHMENTS REQUIRED