BEAUFORT WEST STUDY TRUST

APPLICATION FOR A BURSARY TOWARDS TERTIARY EDUCATION /

AANSOEK OM ‘N STUDIEBEURS T.O.V. TERSIêRE ONDERRIG

(closing date: end October/ sluitingsdatum: einde Oktober)

SECTION I / DEEL I

(To be completed by applicant in own handwriting. Please print /

Om deur aansoeker in eie handskrif te voltooi te word. Gebruik drukskrif asb.)

Full name (s) of applicant (learner):………………………………………………………………………..

Volle naam van applikant (leerder):

Date of Birth / Geboortedatum: ……………………………………………………………………………

Identity number / Identiteitsnommer: ……………………………………………………………………...

Home address / Huisadres: ……………………………………………………………………………….

…….…………………………….…………………………………………….

Code/Kode: …………………...

Postal Address (if not the same): …………………………………………………………………………

Posadres (indien nie dieselfde)

……..…………………………………………………………………..

Code/Kode: ……………………

Tel. No/Nearest Contact no.: Tel. No./Naaste Kontak No.: …………………………………………….

Present School Attending/ ………………………………………………………………………………..

Naam van Huidige Skool

School Address/ ………..……………………………………………………………………….

Adres van Skool ………………………………………………………………………………… Code/Kode:…………………….

Contact Numbers/Kontaknommers:

School/Skool: …………………………… Principal/Skoolhoof: ……………………………..

Latest Exam Results / Jongste Eksamenuitslae:

Subjects/Vakke June/Junie Sept./Sept.

…………………………… ………………………… ……………………………

…………………………… .………………………… ……………………………

…………………………… …………………………. ……………………………

(Attach proof of official results / Bewys van amptelike uitslae moet aangeheg word)

POST MATRIC EDUCATION/NA-MATRIEK OPVOEDING: (If Any – Indien enge)

Name of Institution/Naam van Inrigting: ……………………………………………………..

Course Entered/Kursus waarvoor ingeskryf: …………………………………………..

Year of Study / Jaargang: ..................................................................................

Date of Entry / Datum van toetrede: ....................................................................

EDUCATIONAL BACKGROUND/AKADEMIESE GESKIEDENIS:

MODULES/MODULE YEAR/JAAR

…………………………………………….. …………………………………….

(N.B./L.W.: Attach proof of registration and latest results/Bewys van registrasie en jongste uitslae moet aangeheg word)

Desired Occupation/Beoogde Beroep: ……………………………………………………….

Good

Goed

Satisfactory

Bevredigend

Average

Gemiddeld

Weak

Swak

School Attendance/Skoolbywoning

Weak

Swak

Average

Gemiddeld

Satisfactory

Bevredigend

Good

Goed

School Progress/Skoolvordering GGo

Good

Goed

Satisfactory

Bevredigend

Average

Gemiddeld

Weak

Swak

Church Attendance/Kerkbywoning

(Indicate with cross in appropriate space/Merk met kruisie in toepaslike ruimte)

Religious Denomination/Kerkverband:…………………………………………………………………….

Name of Parish/Naam van Gemeente: …………………………………………………………………...

Are you in receipt of another Bursary? (Yes or No) /

Ontvang u ‘n Ander Beurs? (Ja of Nee): ……………………………………

If “Yes”, Provide Details / Indien “Ja”, Verstrek Besonderhede:

…………………………………………………………………………………………………………………

SECTION II / DEEL II

(To be completed by the class teacher /

Om deur klasonderwyser(-es) voltooi word)

Name of Learner/Naam van Leerder: ………………………………………………………………….

School Grade/Huidige Graad: ……………………………………………

School Year/Skool Jaar: ………………………………………………….

Good

Goed

Satisfactory

Bevredigend

Average

Gemiddeld

Weak

Swak

School Attendance /

Skoolbywoning

Good

Goed

Satisfactory

Bevredigend

Average

Gemiddeld

Weak

Swak

Dedication /

Toewyding

Good

Goed

Satisfactory

Bevredigend

Average

Gemiddeld

Weak

Swak

Self Discipline /

Self Dissipline

Weak

Swak

Average

Gemiddeld

Satisfactory

Bevredigend

Good

Goed

Character /

Karakter

Weak

Swak

Average

Gemiddeld

Satisfactory

Bevredigend

Good

Goed

Participation in extra-mural

activities (i.e. youth, drama) /

Deelname aan buitemuurse

aktiwiteite (bv. jeug, drama)

Good

Goed

Satisfactory

Bevredigend

Average

Gemiddeld

Weak

Swak

Participation in Sport /

Deelname aan Sport

Name of class teacher /:........................................................ Signature/: .......................................

Naam van klasonderwyser Handtekening

SECTION III / DEEL III

FINANCIAL CIRCUMSTANCES/FINANSIëLE OMSTANDIGHEDE

(To be completed by parent of guardian/ Om deur ouer of voog voltooi te word)

Full Name(s) of Parent/Guardian /

Volle Naam van Ouer/Voog: ……………………………………………………………………………….

Age of Parent/Guardian/

Ouderdom van Ouer/Voog: ……………………………………

Home Address of Parent/Guardian /

Woonadres van Ouer/Voog: ……………………………………………………………………….

……………………………………………………………………….

Code/Kode:……………………

Name of Learner (Applicant) /

Naam van Leerder (Applikant): ………………………………………………………………….………..

Is learner related to you in blood? (Yes/No) /

Is leerder ‘n bloedverwant van u? (Ja/Nee): …………………………………….

If not, how is he/she related to you?: ...............................................................................................

Indien nie, aard van verwantskap

HOUSEHOLD EXPENSES / HUISHOUDELIKE UITGAWES:

(1) Rental/Huur: ………….……………………….. (pw of pm)

(2) Bond/Verband: …………………………………(pw of pm):

(3) Municipal services account (i.e. water, electricity, rates) /

Munisipale dienste rekening (bv. water,elektrisitei, belasting: …………………….….(pw of pm)

Employment/Werkgewer:

Name and Address/Naam en Adres: ……………………………………………………….………

………………………………………………………………

……………………………………………………………… Code/Kode: ………………….

Salary/Wages /

Salaris/Loon: ………………………………(pw of pm)

Capacity of Employment /

Hoedanigheid van Werknemer: ………………………………………………………………………….

DOMESTIC CIRCUMSTANCES / HUISHOUDELIKE OMSTANDIGHEDE:

Name of Parent/Guardian

Naam van Ouer/Voog: ……………………………………………………………………………………..

Occupation of Parent/Guardian /

Beroep van Ouer/Voog: ………………………………………………………

Bruts Annual Income/ Less than to to to

Bruto Jaarlikse Inkomste: Minder as tot tot tot

R10 000 R20 000 R30 000 R40 000

R50 000 R60 000 R70 000 R80 000

R90 000 R100 000 R110 000 R120 000

Other Income/Ander Huishoudelike Inkomste:

……………………………………………………………………………………………

N.B. Certified documentary proof to be attached /

L.W. Gesertifiseerde dokumentêre bewyse van inkomste moet aangeheg word.

No. of Dependance: Adults: ……………………… Children: ……………………….

Aantal Afhanklikes: Volwassenes: ……………… Kinders: ……………………….

I, the undersigned require that the following additional information be accepted /

Ek, die ondergetekende, versoek dat die volgende addisionele inligting in aanmerking geneem word:

Signature of parent/guardian /

Handtekening van ouer/voog: …………………………………………….

Date/Datum: ………………………………………….

GENERAL/ALGEMEEN:

Please indicate as to why you selected your chosen field of study /

Dui asseblief aan waarom u hierdie studierigting gekies het

…………………………………………………………………………………………………………………

What contribution will be made towards the community by engaging in your field of study? / Watter bydrae hoop u om tot u gemeenskap te lewer d.m.v. hierdie studierigting?

…………………………………………………………………………………………………………………

Mention all your extra-curricula activities / Noem al die buitemuurse aktiwiteite waarin u betrokke is

…………………………………………………………………………………………………………………

Mention special achievements on your part? / Wat sou u beskou as spesiale prestasies wat u tot dusver bereik het?

…………………………………………………………………………………………………………………

Do you receive any other bursaries(please indicate) / Ontvang u tans enige ander beurse (verskaf asseblief besonderhede)

…………………………………………………………………………………………………………………

Have you applied for any other bursaries, if so, provide details / Het u om enige ander beurse aansoek gedoen? indien wel, verskaf besonderhede

…………………………………………………………………………………………………………………

Motivate why bursary is required (use separate sheet if space is inadequate) /

Motiveer waarom ‘n beurs noodsaaklik is (gebruik ‘n aparte vel indien spasie onvoldoende is)

…………………………………………………………………………………………………………………

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

…………………………………………………………………………………………………………………

VERKLARING/STATEMENT:

I realize that any false or misleading introduction provided by me would lead to disqualification of my application or re-imbursement of funds already received by me.

Ek begryp dat enige vals of misleidende inligting wat op hierdie beursaansoekvorm of in verband met hierdie beursaansoek verskaf word, daartoe mag lei dat die aansoek nie verder oorweeg word nie of dat alle gelde wat reeds betaal is, verhaal word.

Signature/Handtekening: …………………………………………………..

Date/Datum: ………………………………………………………………...

Signature of Parent/Guardian(in case applicant is a minor) /

Handtekening van Ouer/Voog (in die geval van minderjarige): ……………………………………….

NB!! COMMENTS:

(i) Bursary application forms as obtainable from the school principal concerned must be

submitted as fully completed together with the documentation as required on or before 31^st October of each year /

Voltooide beurs-aansoeke moet ontvang word voor of op 31 Oktober jaarliks saam met die vereiste dokumentasie.

(ii) No bursary applications will be considered after the prescribed date as indicated has expired. /

Geen laat-aansoeke sal oorweeg word nie.

(iii) Bursary allocations are considered on an annual basis in the year preceding the desired year

of study./

Beurstoekennings word slegs jaarliks oorweeg in die jaar wat die beoogde jaar van studie voorafgaan.

Beaufort West Study Trust

Pages

Friday, 12 April 2013

Application Form

SECTION I / DEEL I

MODULES/MODULE YEAR/JAAR

SECTION II / DEEL II

SECTION III / DEEL III

FINANCIAL CIRCUMSTANCES/FINANSIëLE OMSTANDIGHEDE

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