2010 NEW APPLICATION FORM

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2010 NEW APPLICATION FORM Powered By Docstoc
					     FREE STATE PROVINCIAL GOVERNMENT
         DEPARTMENT OF THE PREMIER




 LOSING                    2009
CLOSING DATE: 30 SEPTEMBER 2009




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 INSTRUCTIONS FOR COMPLETING THE APPLICATION FORM

 1.       THE FOLLOWING DOCUMENTS MUST ACCOMPANY YOUR APPLICATION:
 1.1      Certified copy of birth certificate or identification document (ID).
 1.2      Certified copy of the salary statement/affidavit of income of your parents or guardians
 1.3      Certified copy of Grade 11 certificate or Grade 12 June examination results/ Grade 12
          certificate
 1.4      If already studying - latest results
 1.5      Salary slips for ALL employees (Part-time Bursary Applications)

 2.       PLEASE PRINT WHEN COMPLETING THE FORM

 3.       MARK APPROPRIATE BLOCKS WITH AN “X”

 4.       THE CLOSING DATE FOR THE SUBMISSION OF THE APPLICATION FORM AND
          ALL THE REQUIRED DOCUMENTS IS 31 August 2009. APPLICATIONS MUST
          BE SUBMITTED TO:
          The Bursary Section             The Bursary Section
          Free State of the Premier       Free State Department of the Premier
          PO Box 517                OR    Second floor Education Building
          BLOEMFONTEIN, 9300              Vista Campus, Church Street, Bloemfontein

 5.       FOR ASSISTANCE INTO PROPER COMPLETION OF THIS FORM, PLEASE
          CONTACT THE BURSARY OFFICE AT ROOM 221/242, THE EDUCATIN BUILDING,
          VISTA CAMPUS, CHURCH STREET, BLOEMFONTEIN. TELEPHONE NUMBERS
          (051) 4096921 / 16.

 6.       IF YOU DO NOT RECEIVE ANY RESPONSE FROM THE BURSARY SECTION
          WITHIN FOUR MONTHS AFTER THE CLOSING DATE FOR APPLICATIONS,
          PLEASE KNOW THAT YOUR APPLICATION WAS UNSUCCESSFUL.

TO BE COMPLETED BY THE APPLICANT AND RECOMMENDED BY:

        TO BE COMPLETED BY:
        THE PRINCIPAL / HEAD OF FACULTY OF APPLICANT: Full-time Bursaries
        THE SUPERVISOR OF APPLICANT: Part-time Bursaries

          Mr / Ms ………………………………………………………… (surname of applicant)

          intends to follow a study field that is relevant to the strategic objectives of the

          Free State Department of ……………………………………………………….……
          for the following reasons:
          ……………………………………………………………………………………………
          ……………………………………………………………………………………………
          and has to my knowledge the ability and drive to make a success of the course.
          I have checked that the application form is completed correctly and that the
          required documents are attached.

          ………………                     ……………………                         …………………
          SURNAME                    INITIALS                         RANK



          …………………………………                                               ………………………
         SIGNATURE                                                    DATE

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                       SECTION A – FOR FULL- AND PART-TIME APPLICATIONS
1. For which academic year do you want a
  bursary?                                                                         2010

2. Type of bursary applying for?                           Full-time                               Part-time

3. ID Number

4. Surname

5. Initials:              First Names:

6. Race                           Black               Coloured                   White                     Indian

7. GENDER:                Male       Female          8. Title                     Mr.                        Me


9. Present postal address where
    correspondence must be posted to
                                                                                           Postal code:

10. Second Address
                                                                                           Postal Code:

11. Home telephone number                         Dialing Code: …………………

                                                  Number: ……………………………….
12. Cell Number
13. E-mail Address
14. SA Citizen:            Yes            No      15. Convicted Criminal                Yes           No
                                                  If “YES” provide details on a
                                                  separate folio.
                                                  17. If disabled specify!
16. Disabled               Yes            No      …………………………………………………….

                                                     A          B        C          D          E         F           G
18. Matriculation year:
                                                     7          6         5         4          3         2           1
Grade 11           or Matric Symbol                1680+       1470/    1260 /    1050 /      840 /     720 /       719 /
                                                               1679     1469      1259        1049      839          0

19. District: please underline.
         Motheo / Xhariep                         20. Name of School: ……………………………
Lejweleputswa       /   Fezile Dabi               School telephone number: …………………….
Thabo Mofutsanyane
                                                  Name of Principal: ……………………………….
21. Post School Qualifications if applicable!     Year
Name of Qualification                             obtained          Name of institution




                  SECTION B FOR EMPLOYEES ONLY (PART-TIME APPLICATIONS)

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22. Department:                                  23. Persal No.                     Salary level:
                                                                                    Notch:
24. Appointment Date:                            25. Nature of appointment:
26 Job Title:                                    27. Educators Post Level:
                                                 (Applicable for Educators only.)
28. Current REQV Level




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29. Subjects / Learning areas currently teaching / Major key responsibilities (for educators)

30. Own office tel. number:               31. Directorate/District:
32. Second tel. number.                   33. Sub-directorate/Sub-District:
                      SECTION C FOR FULL- AND PART-TIME APPLICATIONS
34. Resident of the Free State                     YES                                                NO
35. Are / were you a recipient of a bursary
from any government department or private                        YES                                  NO
company?
36. If “YES” – which government department
or private company?
37 Do you still have bursary obligations to
the relevant government department or                            YES                                  NO
company?
38 If “YES” – how do you have to fulfill your
obligation?                                                    SERVICE                            REFUND
39. Give the name of the institution where
you are / or intend registering/ currently
registered? (University, Technikon, FET
Colleges, other).
Please note:        you may study at an
institution of your choice, but it should be
an accredited learning program at a
registered institution. Preference will be
given to institutions in the Free State.
Please give motivation for studying
outside the Free State boundaries.
40. Name the study field you intend
registering/ currently registered for
example a Degree, Diploma or Certificate
like a B A or ND in Technology, Certificate
in Education, etc (1 study field only)
41.Specializing Field:
Major Subject:                                        42. Expected year of completion …………….

43. Need bursary for how many years……...?             44. Minimum duration of course ……………..?
45. NQF Level – Underline please                      FETC – National Certificates
                                                      GETC – Grade 9/ABET Level 4/National Certificate
                                                      HET – National Diplomas/Certificates
                                                      HET – National First Degrees/Higher Diplomas
                                                      HET – Master Degrees / Honours Degrees
                                                             Professional Qualifications
                                                      HET – Post Doctoral Research Degrees/ Doctorates

46.Study field number of credits?                     47. Estimated cost per year?................................


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48. Current Academic year of present course? ……….               49. Student No: …………………………….

50. Does the study field that you intend registering/ currently registered               YES              NO
appear in the bursary advertisement / circular as an identified need?

51. Will this be your first qualification?                                               YES              NO

52. Application Recommended?
(Principal for Full-time & Supervisor for Part-time bursary applications)                YES              NO

53. Is this your first bursary application?                                              YES              NO

54. All documents attached?                                                              YES              NO
55. Certified copy of your ID?                                                           YES              NO
56. Certified copy of your latest school exam?                                           YES              NO
57. Certified copy of your financial status? (salary slip/affidavit)                     YES              NO
58. Certified copy of your other certificates?                                           YES              NO
59. Copy of your PERSAL salary slip (employees)                                          YES              NO


60. Have you been a Free State Provincial Government bursary holder                      YES              NO
before?

61. If you were a bursary holder before, did you complete your studies?                  YES              NO

62. If “YES”, which year did you complete your studies?
                         SECTION D FOR FULL-TIME APPLICATIONS ONLY

63. Annual income of parents if still a minor: 64. Annual income of Spouse? (If married)
R …………………………….                                 R ……………………………..
      SALARY SLIPS TO BE ATTACHED AND AFFIDAVIT IN THE CASE OF UNEMPLOYED
65. Number of children depending on parent / spouse’ income?
Higher Learning institution? …………… / Attending School? …………… Pre-School? ……………
66. Parent/s work for Free State Provincial    67. Name and address of parent’s employer
Government? Yes / No.
                                               …………………………………………………….

                                                     ……………………………………………………..

                                                     ……………………………………………………..

                                                     Tel No: ……………………………………………




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SECTION D: DECLARATION BY APPLICANT:

         I (initials and surname) …………………………………………………………… declare that:

1        the above particulars are complete and correct and I understand that any false information
         supplied, will lead to the immediate cancellation of the bursary,

2        all documents required are attached - if not – I understand that it will lead to the immediate
         cancellation of my application,

3        I understand that this application is for a bursary and not a loan and intend making my services
         available to the Department of the Premier upon obtaining the qualification in terms of the bursary
         contract, which is to be entered into if I am successful in my application for a bursary,

4        I understand that this bursary must be utilized as from the 2010 academic year and cannot be
         transferred to the following year or to another person and that no outstanding balances from
         previous academic years will be paid,

5        I understand that if I receive a bursary it is my responsibility to register at a registered and
         accredited Higher or Further learning institution in the Free State and to effect payment, submit
         my bursary contract, specified account and grade 12 final results before 24 February 2010 to
         the bursary section, Room 221/242, Education Building, Vista Campus, Church
         Street, Bloemfontein. If I do not, I am aware that my bursary will be deemed cancelled,

6        I understand that no payment will be made before all documentation has been submitted.

7        I understand that I have to comply with the following to be considered for a bursary:

             •    be a Free State citizen
             •    provide proof of the financial circumstances of my parents or guardian
             •    select a study field from those that appear on page one of the advertisement
             •    be recommended by the Principal
             •    study full-time should I be successful in my application
             •    submit the required documents
             •    complete the application form correctly
             •    be obliged to enter into a contract with the Department of Education


SIGNATURE OF APPLICANT:…………………………………..DATE:……………………………



SIGNATURE OF PARENT/GUARDIAN: ……………………………DATE:……………………
(If applicant is under the age of 21)




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