HCI Foundation BURSARY FUND APPLICATION FORM.pdf

OFFICIAL USE ONLYBURSARY FUND APPLICATION FORM 2011Guide to complete1. Please complete all information requested on the application form2. Write clearly and legibly (please PRINT)3. Please ensure that all documents requested are certified copies and are submitted with thisapplication form. (Your local Post Office or Police Station will be able to certify documents)4. Please make sure you provide us with your correct address for correspondence to ensure thatyou will receive our mail. Please inform us of any change of address.Applications to be posted to either:The HCI FoundationP.O. Box 4064Cape Town 8000OrBlock A Longkloof StudiosDarters RoadGardens 8001Email: bp@hcifoundation.co.zaClosing DateFriday 15 October 2010 PLEASE NOTE THAT APPLICATIONS RECEIVEDAFTER THIS DATE WILL NOT BE ACCEPTEDIs this application submitted via an HCI subsidiary company?If yes which company YesCompany Stamp1. PERSONAL DETAILS OF STUDENT NoSURNAMEFIRST NAMES IN FULL GENDER F MID NUMBERDATE OF BIRTHETHNIC GROUPBlackIndianWhiteColoured*Collected for Statistical Purposes onlyNATIONALITYHOME ADDRESSSA Citizen Non SA Citizen RefugeeADDRESSWHILE STUDYINGPostal CodePostal CodeCELL NO.EMAILTELEPHONE01

2. FAMILY DETAILSFather/GuardianSURNAMEFIRST NAMES IN FULLHOME ADDRESSPostal CodeTELEPHONE (H)EMPLOYEREMPLOYER TEL.INCOMEMother/GuardianSURNAMEFIRST NAMES IN FULLHOME ADDRESSPostal CodeTELEPHONE (H)EMPLOYEREMPLOYER TEL.INCOMECurrent Maritial Status of Parents/GuardiansMarried Cohabitating Married but separated Divorced Single3. DETAILS OF PROPOSED STUDY DURING 2011COURSE OF STUDYYEAR OF STUDY IN 20111st 2nd 3rd 4th 5th 6thSTUDENT NUMBERSTART DATE OF STUDYMonth YearNAME OF UNIVERSITY/UOT/COLLEGECOST OF COURSE FEES PER ACADEMIC YEAR02

HAVE YOU RECEIVED A BURSARY FROM HCI FOUNDATION IN THE PAST?IF YES COMPLETE THE FOLLOWINGYear ReceivedYesAmount ReceivedNoDO YOU EXPECT TO RECEIVE A BURSARY /STUDY LOAN FROM ANOTHER SOURCE?IF YES COMPLETE THE FOLLOWINGYesNoName of Institution Year Received Amount Received4. EMPLOYMENTARE YOU CURRENTLY EMPLOYED? Yes NoIF YES COMPLETE THE FOLLOWINGSelf EmployedPart Time EmploymentYes No Income per MonthIF EMPLOYED, IS YOUR EMPLOYER CONTRIBUTING TO YOUR STUDIES? Yes NoIF YES HOW MUCH?5. COMMUNITY INVOLVEMENTARE YOU INVOLVED IN LOCAL COMMUNITY ORGANISATIONS, SCHOOL,COLLEGE OR UNIVERSITY ACTIVITIES? Yes NoIF YES, WHICH?03

DECLARATIONI, ……………………………………. the undersigned hereby declare that the information provided in thisapplication is to the best of my knowledge true and accurate. I hereby undertake to inform HCI Foundation ofany changes in my circumstances. I acknowledge that should I fail to inform HCI Foundation of any changesin my financial situation and continue to receive financial aid not due to me, HCI Foundation will have recourseagainst me.Signature of ApplicantDatePlease make sure the following documents are enclosed:SUPPORTING APPLICATION DOCUMENT CHECKLISTAttached?YESNO1. CERTIFIED COPY OF ID DOCUMENT2. CERTIFIED PROOF OF PARENT(S) / GUARDIAN(S) LATEST SALARY,GRANT OR INCOME3. AFFIDAVIT CONFIRMING UNEMPLOYMENT, ELDERLY, DISABLED,SICKLY DEPENDENTS4. A CERTIFIED COPY OF STD 10 / GRADE 12 (1 ST YEARS ONLY) (OR)5. A CERTIFIED COPY OF THE RESULTS FOR THE PREVIOUS STUDY YEAR(COLLEGE / UNIVERSITY / UOT STUDENTS APPLYING FOR 2 ND ORSUBSEQUENT STUDY YEAR)6. OFFICIAL LETTER OF ACCEPTANCE FROM COLLEGE / UNIVERSITY /UOT WITH REGARD TO THE COURSE APPLIED FOR7. DETAILED QUOTATION OR STATEMENT FROM INSTITUTIONINDICATING COURSE FEES FOR THE FULL ACADEMIC YEARIMPORTANT NOTICEPlease make sure that this form reaches us before the closing date. Should you still have any outstandingdocuments please inform us in writing. It remains your responsibility to submit outstanding documentstimeously in order to prevent delays to the processing of your application.The Foundation will not pursue missing information. Incomplete applications will be disqualified.The decision of the HCI Foundation is final and no correspondence will be entered into.Closing DateFriday, 15 October 2010PLEASE NOTE THAT APPLICATIONS RECEIVED AFTER THIS DATE WILL NOT BE ACCEPTED04