SECTION 3:

TECHNOLOGICAL INFORMATION:

Type of Devices Number of devices in family Device mainly used by (include full name).

Desktop

Laptop

Tablet
DEVICE PROVISION
A SEPARATE FORM MUST BE FILLED OUT FOR EACH STUDENT
Smartphone
SECTION 1:
STUDENT INFORMATION:
Yes No
First Name Surname
Connectivity at home
address Name of Student
Home Internet Mobile Data

Gender Female Male

SECTION 4: Date of Birth (dd/mm/yyyy)

Please ensure that you have attached: (i) stamped payslip/job letter or (ii) two (2) stamped copies of letters of recommendation.
Please note that all successful applicants will be required to sign a contract. Home Address

DECLARATION
Name of School

I, the undersigned, hereby declare that the particulars I have supplied are true and complete. Class/Form

Email (where applicable)

Signature of Primary Caregiver: Da te:
PRIMARY CAREGIVER INFORMATION
Primary Caregiver is the parent or legal guardian of the child. Information should be entered for both parents/guardians if they live in the same
household where applicable.
OFFICAL USE:
Primary Caregiver # 1
Officer’s Name: First Name Surname
Name
Signature of Officer: Date:
Relationship to student

Gender Female Male

........................................................CUT ALONG THIS LINE................................................................................................................................................
RECEIPT: Date of Birth (dd/mm/yyyy)
This receipt is to verify that you have submitted the application form for Device Provision Married Divorced/Separated Common-law Single

Status
Primary Caregiver’s Name: ______________________________________________ ID (ID/PD/PP) No. __________________
Home Address
Primary Caregiver’s Signature: _____________________________________________
(Attach recent utility bill as proof of

Verified by: (Officer’s Name) : ___________________________________________ address)

National Identification Driver’s Permit No. Passport No.
National Identification
Card No.
Signature of Officer: ____________________________________________________
(At least one)

Date:_________________________________________________________________ Mobile Residential Phone E Mail Address

Contact information
________________________________________________________________
 SECTION 2:
Primary Caregiver # 2 CAREGIVER FINANCIAL INFORMATION:
For self-employed persons, an average of their monthly income over the last 3 months should be given.
First Name Surname
Name
Caregiver #1
Relationship to student Employment Status
Gender Female Male
Yes No Self-employed Yes No
Date of Birth (dd/mm/yyyy)
Married Divorced/Separated Common-law Single Other, please state:
Employed
Part time Permanent Contract
Status

Home Address Occupation

(Attach recent utility bill as proof of
Name and Address of Employer
address)
National Identification Driver’s Permit No. Passport No. Salary: Government Assistance: Yes No
National Identification
Card No.
(At least one) Monthly Income $
If yes, state the sum $
Mobile Residential Phone E Mail Address
Contact information
Caregiver #2

Yes No Self employed Yes No

OTHER CHILDREN INFORMATION:
Other, please state:
Employed
Number of dependents aged 3-18 of the primary caregivers Part time Permanent Contract

Name of child Age Relationship to Ap- School Level Name of school Owns
plicant Device
(ECCE, Primary, Occupation
Secondary) Yes/No
Name and Address of Employer
1.
Salary: Government Grants: Yes No

Monthly Income $
2. If yes, state the sum $

3.
For persons not self-employed, a current job letter/payslip (not older than 3 months and stamped by the employer) is re-
quired.
For self-employed persons, submit TWO (2) stamped copies of letters of recommendation
4
The Recommender must not be an immediate relative of the applicant.
The Recommender must be included in one of the following categories:
 Minister of Religion registered under law to perform marriages.
5.
 Managing Director, Director and Managers of Banks and companies.
 Member of Parliament, Mayor, Borough or County Councillor.
 Notary Public or Justice of the Peace or Commissioner of Affidavits.
 Senior Public Servants (Range 30 and above).
 Police Officer (Corporal and above rank) (Include Regimental Number).
Total devices applied for under the DEVICE PROVISION programme ________________  Fire Sub-Officer and above rank (Include Regimental Number).
 Prison Officer II and above rank (Include Regimental Number).
 Member of the Defence Force (Corporal/Leading Seaman and above rank)
 School Principal, Vice-Principal, Lecturer, Graduate Teacher (Teacher I and above rank)

These letters/recommendations should verify that the applicant is self-employed and state the profession.