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BURSARY APPLICATION for FULL-TIME STUDY IN HEALTH SCIENCES FOR 2011 ACADEMIC YEAR BEURS AANSOEK vir VOLTYDSE STUDIES IN GESONDHEIDS WETENSKAPPE VIR 2011 AKADEMIESE JAAR

Closing Date:06 September 2010 Important

Belangrik

(i)

Please complete in CAPITAL LETTERS.

(i)

Voltooi in HOOFLETTERS

(ii)

Mark appropriate blocks where necessary.

(ii)

Merk toepaslike blokkies waar nodig

(iii)

Incomplete and or incorrect applications will not be consideredPlease note: Should any of the following documents not be attached, your application will be considered as incomplete:

(iii) Onvolledig en onvoltooide aansoeke sal nie oorweeg word nie.Neem kennis: Indien enige van die volgende dokumentasie nie aangeheg is nie, sal u aansoek as onvolledig beskou word.

(iv)

CERTIFIED documents to be submitted:

(iv) GESERTIFISEERDE dokumente wat hiedie aansoek moet vergesel:

(v)

1. RSA ID document

1. RSA ID dokument

2. Proof of previous academic year’s results or Matric certificate.(if currently in Matric,please submit Grade 12 results for June/September 2010)

2. Bewys van uitslae van vorige akademiese jaar of Matriek sertifikaat.(indien huidiglik in Matriek,voorsien asseblief Junie/September 2010 Grade 12 uitslae)

POST/HAND DELIVER the application to: THE DIRECTORATE: HUMAN RESOURCE DEVELOPMENT,IMPLEMENTATION, DEPARTMENT OF HEALTH, PO BOX 2060, and 4 DORP STREET CAPE TOWN 8000. ATT: ASHLEY THORNE

(v)

POS/HAND AFLEWER die aansoek aan: DIE DIREKTORAAT: MENSLIKE HULPBRONONTWIKKELING,UITVOERINGS EENHEID, DEPARTEMENT VAN GESONDHEID, POSBUS 2060, 4 DORP STRAAT KAAPSTAD 8000. VIR AANDAG: ASHLEY THORNE

*NO FAXED OR E-MAILED APPLICATIONS WILL BE CONSIDERED.

GEEN FAKS OF E-POS AANSOEKE SAL ANVAAR WORD NIE.

Please note: The final award of a bursary is subject to your acceptance at a Higher Education Institution

Neem Kennis: Die toekenning van n beurs is afhangende van u aanvaarding by n Hoer Onderwys instansie.

SURNAME:

NAME: ID NUMBER:


SECTION A: DETAILS OF STUDENT AND PLANNED COURSE OF STUDY

PERSONAL INFORMATION 1 Surname

3 Title Titel

Van 2 First names Voorname 4 Date of birth/ Geboorte datum

5 Language/ Taal DD

MM

YYYY

6 Current Home address / Huisadres

8 P. Postal address / Posadres (Please attach proof of permanent postal address, eg. Affadavit , Lease agreement Pg1, account statement, etc)

Please attach proof of current residential address, eg. Affadavit, Lease agreement Pg1, account statement, etc)

Province Provinsie

/

7 Telephone Number / Telefoonnommer

Postal Code / Poskode Province /Provinsie 9 Telephone Number / Telefoonnommer

Code/Kode

10 Cell number Selfoon Nommer

Postal Code / Poskode

Code/Kode

11 E-mail Address E-pos Adres

12 a) Are you in receipt of another bursary,rebate and or sponsorship?

EQUITY INFORMATION

Is u tans in ontvangs van eniger ander beurse of borgskap

Note:Section 14 is included in terms of the employment equity act of 1998 no.55 of 1998 and its definition of designated groups.

YES

NO

14 (a

Male Manlik

Female Vroulik

14 (b

Black

Coloured

Indian

White

Swart

Kleurling

Indiër

Wit

If "YES" furnish particulars below / Indien "JA" verstrek i) Sponsor/Borgskap besonderhede

(i.e. Bank,NSFAS,TEFSA,ETC)

13 Fullfillment obligations/Vervulling van verpligtinge Work back Terug werk

Pay back Terug betaal

Single Ongetroud

None

Disability

YES

NO

Geen

Gestremd

JA

NEE

PLEASE NOTE: candidates whose parents are in the employ of an accredited HEI and who qualify for bursary support for their children will receive 50% of the Departmental disbursement (in terms of the Departmental Policy Guidelines for Full-Time Higher Education Bursaries, Section 10.3.3).

Married Getroud

If “YES” furnish particulars / Indien “JA” verstrek besonderhede.

Course information which bursary is needed for 15 NAME OF COURSE: (MBCHB; B PHARMACY, B CUR NURSING,etc )

16

TRAINING PROVIDER

(eg, CPUT.UWC.UCT.US,) 17. NUMBER OF YEARS TO COMPLETE QUALIFICATION

18 QUALIFICATION ALREADY OBTAINED

years


SECTION B: DETAILS OF PARENT/S OR LEGAL GUARDIAN/S OR SPOUSE 19 a)

Surname of parent, legal guardian or spouse Van van ouer, voog of eggenoot/e

b)

Initials

Title

Voorletters

Titel

Address of parent, legal guardian or spouse Adres van ouer, voog of eggenoot/e

c)

Telephone Number (Home)

d)

Cell Phone Number Selfoon Nommer

e)

Code/Kode

Telephone Number (Work) Telefoonnommer (Werk)

Employer of parent, legal guardian or spouse

Code/Kode

Parent/Voog 1

Werkgewer van ouer/s, voog of eggenoot Parent/Voog 2

Employer of parent, legal guardian Werkgewer van ouer/s, voog of eggenoot/

f)

g)

Gross Income of Parent/s, legal guardian or spouse (Cross appropriate box for each parent or guardian) Bruto inkomste van ouer, voog of eggenoot/e (Maak ‘n kruis in die toepaslike blok vir elke werkende ouer/voog of eggenoot) PARENT 1

Under R70 000 per year

R70 000 - R100 000 per year

Over R100 000 per year

OUER 1

Onder R70 000 per jaar

R70 000 - R100 000 per jaar

Oor R100 000 per jaar

PARENT 2

Under R70 000 per year

R70 000 - R100 000 per year

Over R100 000 per year

OUER 2 Onder R70 000 per jaar R70 000 - R100 000 per jaar Oor R100 000 per jaar Total combined income(Cross appropriate box for the combined income of both parents or gaurdians) Bruto gekombineerde inkomste(Maak n kruis in die toepaskike blok vir die gesamentlike inkomste van albei ouers of voee) Under R70 000 per year

R70 000 - R100 000 per year

Onder R70 000 per jaar

R70 000 - R100 000 per jaar

Under R70 000 per year

R70 000 - R100 000 per year

Onder R70 000 per jaar

R70 000 - R100 000 per jaar

Over R100 000 per year Oor R100 000 per jaar Over R100 000 per year Oor R100 000 per jaar

Aantal kinders afhanklik van bogenoemde inkomste Total number of children dependant on abovementioned income

SECTION : DECLARATION BY STUDENT AND LEGAL GUARDIAN 20 I declare that the above information is complete and correct and that the applicant intends making his/her services available to the Department of Health upon obtaining the qualification for which the bursary is granted. Ek verklaar dat bostaande gegewens volledig en korrek is en dat die applikant, by verwerwing van die betrokke kwalifikasie/s, van voornemens is om dienste ingevolge die beurskontrak wat aangegaan sal word, aan die Department van Gesondheid beskikbaar te stel. Please note: The Department of Health reserves the right to cancel any application which it deems to be fraudulent or incorrect.

Signature of applicant

Date

Signature of parent or legal guardian

Date

Handtekening van

Datum

(if applicant is under 21)

Datum

Handtekening van ouer of voog (indien applikant minderjarig is) Where did you hear about the bursary?

Word of mouth

Media Please specify.

Institution Please specify.

Other Please specify.


“ONLY THOSE WHO STRIVE FOR SUCCESS ACHIEVE EXCELLENCE”

DEPARTMENT OF HEALTH: BURSARY COMPONENT CONTACT DETAILS: Mrs G George: 021 483 3465/ gageorge@pgwc.gov.za Ms J September:021 483 2806/ Jaseptem@pgwc.gov.za Mr M Strydom: 021 483 6610/ Mostrydo@pgwc.gov.za Mr K Mullins: 021 483 2515/ Kmullins@pgwc.gov.za P O Box 2060, Cape Town, 8000


Full-Time Bursaries Dept of Health application_form