Kwazulu-Natal: Government

KWAZULU-NATAL
GOVERNMENT
PROVINCIAL BURSARY
APPLICATION FORM
FOR 2023 ACADEMIC YEAR
Name of Department to which application is addressed: pcstmnt opctt

U nence
end tcaetbne
Name of the applicant: . NhHeq
University you intend to study in: nty hwsh Neqi
Name of the degree or diploma which you are applying for:.

onpt
District:linq tshwrye Uisia 0ton Gtndg cclnol
with the fo
nstruction: Your
documentation:
completed Application Form must be accompanied followin
An originally certified copy of an official statement of results as well
as official
of certificate (matriculation exemption) if it is a requirement for
bachelor's
the course of studyw intend
you following.
2) An originally certified copy of your official study record showing marks, symbols,
Percentagesobtained in all examinations written (including the matriculation
examination).
3) An originally certified copy of your identity document for Parents and yours.
4) Copy of the admission requirements from the academic institution for the
intended course of study if you have not already been accepted.
5) Copy of the
curriculum (indicating the number of years of study, number of
modules/subjects to be taken) from the academic institution for the intended
course of study.
6) Printout from the academic institution of the tuition fees that will be
required only on the progressing students). required
7) Income and expenditure statement of parent/legal

must be provided) or a letter from the guardian. (Proof of income
Department of Labour or an affidavit from
parent/s stating that they are unemployed.#NB Both Parents
8) Originally certified death certificate/s of parent/s.
9) Letter of motivation (explain why you believe you
outlining your circumstances).
are deserving of a
bursary
Please turn over to complete the form
2
Please print when completing this form. Mark Submitthe completed application form and
appropriate blocks with an "X" Failure to the relevant attachments as per address
complete this application form fully and supplied in the advertisement.
correctly may prejudice the applicant's
chances of obtaining a bursary.
PERSONAL PARTICULARS
FIRST NAMES: MHLENGI lISEMAN
SURNAME: MBUiSA
IDENTITY NUMBER: OlOO3S02 O6 DATE OF BIRTH: O3/os/200/
POSTAL ADDRESS: MvuTSHINI_AREA PHYSICAL ADDRESS: 20 0'FLAHEETY 28

ERIVATE BAá XjOG DuRBAN
NKANSLA 33 SS
TELEPHONE NUMBER: ( _ NA DISTRICT:_KiNG CETsHwAJO
CELL PHONE NUMBER: 663 UsG LOCAL MUNICIPALITY: NKANDLA
ALTERNATE NUMBER: 08 814 s243 WARD NUMBER:0
FAX NUMBER: J/A COUNCILLOR:
NATIONALITY: A SOuTH AFEIAN MARITAL STATUS:

SingleMarried/Divorced/Widowed
GENDER:(Malefemale DISABILITY: YESNO

Are you currently employed? YES(NOI yes,
RACE:(BlackColoured/Indian/ White please elaborate_
Have you ever been convicted of a criminal Did you consult a vocational counsellor
offence, dismissed from employment or regarding your choice of study?
requested to resign? YES(NO
If the answer is yes please furnish full details
on a separate sheet of paper.
YESNO
3
Have you previously received a Public Service Bursary? YES{NO)
If yes until which
year? NA
Where did you hear about this bursarieSs:
LNTGRNET
Are/were you in possession of another bursary/scholarship/financial aid? YES/NO
f the answer is yes pleaseindicate the name of the donor:.

Obligations attached to bursary/scholarship/tinancial aid:
Have all the obligations been fulfilled? YES/NO
Name of the degree or diploma which you are applying for:

acuelUr
What will the Cene CCSIT)
major subjects be for the degree
or diploma?
omputor dcicnce n lnfoomotun leali nsloph
Number of years you intend studying for:
yers
Name of tertiary institution you intend studying at
/niversht o1 kweluls-Nafa
Provisional acceptance from the tertiary institution at which you intend
studying
Received or Not Received:_Meceived
QUALIFICATIONS
Highest standard passed: Name of school attended:
rade /R Bizimal Seconary Scheej
Town/city:
Nhaned/a
UNIVERSITY AND/OR OTHER POST SCHOOL TRAINING/STUDIES
List the subjects passed thus far: Address of institution/college:
4
Mau /uO
Phky_ 13
/STN_/03
CovuP lo2
Current year of study: Name of degree/diploma

MCar arCLaelor Sonee
What is the remaining duration of your current List the subjects that still need to be completed
studies as prescribed by the tertiary institution? toobtain the relevant qualification:
2 year
STN 21/|
MATH 236
Please indicate the year you started studying for Have you ever failed any year of study?
the current course of studies: YES/NO
3 tars
Which year?
Have you rewritten the examination/s tor the Student number at current institution:
subject/s failed? If yes, please indicate the date
of the examination: 22003EESL
Full name of parent/legal guardian (if applicable):
iHornbi NL leRan
Contact details of parentlegal guardian:
Tel Number: /A Cell phone number: + 6 220 71G
Address of parent/legal guardian:
Musi
Mand la
33S
Employer of parent/legal guardian:
Address of employer of parent/legal guardian:

A
REVIEW, SUSPENSION AND EXTENSIONN
The Provincial Administration reserves the right, at any time and on any terms or conditions to
a) review the continuation of the bursary; or
b) suspend the bursary: or
C) having suspended the bursary, reinstate the bursary; or
d) Extend the period of the bursary.
DECLARATION
Tunderstand that this application for a bursary is not a loan and declare that the above particulars
are complete and correct.
6
3003Py23
SIGNATURE OF APPLICANT DATE
WITNESSS DATE
A 70/08/2.
WITNESS DATE
SIGNATURE OF PARENT/LEGAL GUARDIAN NNema

DATE: 20/ / 2 P
3u 03/2
WITNESS DATE
u/u/a)
WITNESS DATE
7
FOR OFFICE USE ONLY
RECOMMENDATION BY:
NAME SIGNATURE
DATE:
FOR OFFICE USE ONLY
RECOMMENDATION BY HRD/ BURSARY COMMITTEE
NAME OF CHAIRPERSON SIGNATURE
DATE:

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KWAZULU-NATAL

Name of Department to which application is addressed: pcstmnt opctt

Name of the degree or diploma which you are applying for:.

7) Income and expenditure statement of parent/legal

Please turn over to complete the form

FIRST NAMES: MHLENGI lISEMAN

IDENTITY NUMBER: OlOO3S02 O6 DATE OF BIRTH: O3/os/200/

POSTAL ADDRESS: MvuTSHINI_AREA PHYSICAL ADDRESS: 20 0'FLAHEETY 28

CELL PHONE NUMBER: 663 UsG LOCAL MUNICIPALITY: NKANDLA

ALTERNATE NUMBER: 08 814 s243 WARD NUMBER:0

FAX NUMBER: J/A COUNCILLOR:

NATIONALITY: A SOuTH AFEIAN MARITAL STATUS:

GENDER:(Malefemale DISABILITY: YESNO

f the answer is yes pleaseindicate the name of the donor:.

Have all the obligations been fulfilled? YES/NO

Name of the degree or diploma which you are applying for:

UNIVERSITY AND/OR OTHER POST SCHOOL TRAINING/STUDIES

List the subjects passed thus far: Address of institution/college:

Current year of study: Name of degree/diploma

Address of employer of parent/legal guardian:

REVIEW, SUSPENSION AND EXTENSIONN

a) review the continuation of the bursary; or

b) suspend the bursary: or

C) having suspended the bursary, reinstate the bursary; or

d) Extend the period of the bursary.

SIGNATURE OF PARENT/LEGAL GUARDIAN NNema

FOR OFFICE USE ONLY

RECOMMENDATION BY HRD/ BURSARY COMMITTEE

NAME OF CHAIRPERSON SIGNATURE

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