Verification of Campus

Purpose of this form

Campus details

To verify your place of study to assess your eligibility for Relocation

Scholarship. If you do not provide evidence that you are attending
a regional campus you may not qualify for Relocation Scholarship.

Please provide details of the institution(s) and campus you are

attending. If you are studying at two campus(es) you need to
provide details of both campus(es).

For more information, go to our website

humanservices.gov.au/relocationscholarship

2a Campus 1

www.

Name of educational institution (e.g. university name)

Who should fill in this form

Campus location (i.e. address of physical location you attend)

PART A (Questions 1 to 4) to be completed by the student.

PART B (Question 6) to be completed by an authorised officer
at the campus(es) you attend.

Postcode

Returning your form

Period of enrolment at this campus
From
To

Check that all questions are answered and the authorised officer
has signed and dated this form at PART B question 6.

Please make sure that the authorised officer has placed their
institutions official stamp in the space provided at PART B
question 6.

Name of educational institution (e.g. university name)

Campus location (i.e. address of physical location you attend)

Postcode
Period of enrolment at this campus
From
To

PART A to be completed by the student

Your details

Family name

Go to 3
First given name

Second given name

Date of birth
/

Student Identification Number

CLK0SY101 1411

SY101.1411

2b Campus 2 (if applicable)

You can return your completed document(s) by:

going to myGov website, signing into your account and
selecting Centrelink Services. You can upload your evidence
by selecting Documents and Statements from the menu.
If you do not have myGov account, you need to create one
first and link to Centrelink.
if using one of our Express Plus mobile apps, select Upload
documents from the menu.

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Privacy and your personal information

Your personal information is protected by law, including the
Privacy Act 1988, and is collected by the Australian
Government Department of Human Services for the
assessment and administration of payments and services. This
information is required to process your application or claim.
Your information may be used by the department or given to
other parties for the purposes of research, investigation or
where you have agreed or it is required or authorised by law.
You can get more information about the way in which the
Department of Human Services will manage your personal
information, including our privacy policy at
humanservices.gov.au/privacy or by requesting a copy from
the department.

PART B to be completed by authorised officer

www.

Privacy and your personal information

Your personal information is protected by law, including the
Privacy Act 1988, and is collected by the Australian
Government Department of Human Services for the
assessment and administration of payments and services.
Your information may be used by the department or given to
other parties for the purposes of research, investigation or
where you have agreed or it is required or authorised by law.
You can get more information about the way in which the
Department of Human Services will manage your personal
information, including our privacy policy at
humanservices.gov.au/privacy or by requesting a copy from
the department.
www.

Statement
I declare that:
the information I have provided in this form is complete and
correct.
I understand that:
giving false or misleading information is a serious offence.
the Australian Government Department of Human Services
can make relevant inquires to make sure I receive my correct
entitlement.

I declare that the student whose details appear at Question 1 of

this form is enrolled at the institution and attending the
campus/es shown at Question 2.

6a Campus 1 Name of authorised officer

Phone number (

Signature of authorised officer

Your signature

Date

Campus/institution official stamp

Date
/

Note: Before returning this form, please check that all

questions are answered and the authorised officer has signed,
dated and placed their institutions official stamp on this form
at PART B question 6.

6b Campus 2 Name of authorised officer

Phone number (
Signature of authorised officer
Office use only
Determined
/

Logon ID
/

Date

Verification approved

Campus/institution official stamp

Verification NOT approved

SY101.1411

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