Application Form 2016-2017 - Roscommon County Council
ROSCOMMON COUNTY COUNCIL COMHAIRLE CONTAE ROS COMÁIN THE DERMOT EARLEY BURSARY 2016/2017 APPLICATION FORM Personal Details of Nominee Please tick one box:
Male Athlete
Name: Home Address:
Phone Number: (home)
Female Athlete
Date of Birth:
(mobile)
Secondary School Attended: Your Sport:
Academic Details Please provide details of the Third-Level Course for which the nominee has applied: Course Title and Code: Year of Leaving Certificate: Leaving Certificate Subject
H/O Result
Leaving Certificate Points: Leaving Certificate Subject
H/O Result
Other Exams taken (e.g. FETAC Level 2): Other Academic Achievements:
Roscommon County Council Dermot Earley Bursary 2016/2017
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References Please list two references, not related to the nominee, from whom Roscommon County Council can obtain a personal and sporting reference.
Referee (Academic) (e.g. School Principal)
Referee (Sporting) (e.g. County Team Manager)
Name Address Contact Number:
Sporting Details Club Name:
Grade:
Club Contact: Give a brief account of nominees involvement in his/her chosen sport Also please give details of any current assistance that the nominee may be receiving:
List any achievements or honours: (school, club, county, national / international)
Briefly outline other sports in which the nominee is actively involved:
Roscommon County Council Dermot Earley Bursary 2016/2017
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Personal Best 1
2
3
4
Event Personal Best (time,distance,score) Date achieved Evidence provided
Ranking/Representative Events over the last 18 months: Highest representative achievements TEAM SPORTS (evidence must be supplied) Inter provincial level e.g. Connaught National Level e.g. Irish Schools/Senior County Club
National Rankings INDIVIDUAL SPORTS (evidence must be supplied) Inter provincial ranking e.g. 2nd u17 high jump National Ranking e.g. 1st 100m sprint Club
Additional Achievements: Outline any other significant sporting results over the last 18 months:
Roscommon County Council Dermot Earley Bursary 2016/2017
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Sporting and academic aims: Outline your nominees sporting and academic aims Sporting aims:
Academic:
Other Information Please outline other information relevant to this application (e.g. Community Involvement)
Signed: _____________________________________ Contact number: _____________________
Date: ____________________
Club Name: ___________________
Nominator: ____________________________ I agree to have this application submitted on my behalf: Signed: ___________________________________ Date: ___________________ Nominee: Please return this completed form to Patricia Bohan, Administrative Officer, Corporate Services, Roscommon County Council, Arás an Chontae, Roscommon. Before 5.00 pm on Friday 26th August, 2016.
Roscommon County Council Dermot Earley Bursary 2016/2017
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Male Athlete
Name: Home Address:
Phone Number: (home)
Female Athlete
Date of Birth:
(mobile)
Secondary School Attended: Your Sport:
Academic Details Please provide details of the Third-Level Course for which the nominee has applied: Course Title and Code: Year of Leaving Certificate: Leaving Certificate Subject
H/O Result
Leaving Certificate Points: Leaving Certificate Subject
H/O Result
Other Exams taken (e.g. FETAC Level 2): Other Academic Achievements:
Roscommon County Council Dermot Earley Bursary 2016/2017
Page 1/4
References Please list two references, not related to the nominee, from whom Roscommon County Council can obtain a personal and sporting reference.
Referee (Academic) (e.g. School Principal)
Referee (Sporting) (e.g. County Team Manager)
Name Address Contact Number:
Sporting Details Club Name:
Grade:
Club Contact: Give a brief account of nominees involvement in his/her chosen sport Also please give details of any current assistance that the nominee may be receiving:
List any achievements or honours: (school, club, county, national / international)
Briefly outline other sports in which the nominee is actively involved:
Roscommon County Council Dermot Earley Bursary 2016/2017
Page 2/4
Personal Best 1
2
3
4
Event Personal Best (time,distance,score) Date achieved Evidence provided
Ranking/Representative Events over the last 18 months: Highest representative achievements TEAM SPORTS (evidence must be supplied) Inter provincial level e.g. Connaught National Level e.g. Irish Schools/Senior County Club
National Rankings INDIVIDUAL SPORTS (evidence must be supplied) Inter provincial ranking e.g. 2nd u17 high jump National Ranking e.g. 1st 100m sprint Club
Additional Achievements: Outline any other significant sporting results over the last 18 months:
Roscommon County Council Dermot Earley Bursary 2016/2017
Page 3/4
Sporting and academic aims: Outline your nominees sporting and academic aims Sporting aims:
Academic:
Other Information Please outline other information relevant to this application (e.g. Community Involvement)
Signed: _____________________________________ Contact number: _____________________
Date: ____________________
Club Name: ___________________
Nominator: ____________________________ I agree to have this application submitted on my behalf: Signed: ___________________________________ Date: ___________________ Nominee: Please return this completed form to Patricia Bohan, Administrative Officer, Corporate Services, Roscommon County Council, Arás an Chontae, Roscommon. Before 5.00 pm on Friday 26th August, 2016.
Roscommon County Council Dermot Earley Bursary 2016/2017
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