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2022 BURSARY APPLICATION FORM

Closing date : 07 January 2022

SECTION A
NB: All sections of this application form must be completed in full by the applicant

1. APPLICANT’S DETAILS:
NB. Surname and all Names as they appear on the Green Bar coded Identity Document) / Smart card

Kgasu
Surname: _________________________Name/s: Mosa
______________________________________________________

Male 0103245905080 Kgasumosa2001@gmail.com

Gender:__________ ID NO: _____________________________E-mail Address _____________________________

10368 Ext 8 Ipelegeng, Schweizer reneke

Postal Address: ________________________________________________________________Code 2780
____________

0657432973 0764486199
Student Contact No.: ____________________________ alternative number: ______________________________

0738189511
Parents / Guardian Contact/s ________________________________ / ____________________________________

10368
Permanent Residential /Home Address: House No:_______________________________

Ext 8
Street /Section / Block / Unit / Extension:____________________________________________________________

Schweizer reneke, Ipelegeng

Name of Village / Town / Farm / Township: __________________________________________________________

Type of place (Tick block with X) Village Township X Small Dorpie Town Farm

DISTRICT MUNICIPALITY
(Tick block with X):
Ngaka M. Molema Bojanala Dr. R.S. Mompati X Dr. K. Kaunda

LOCAL MUNICIPALITY: Mamusa local municipality WARD NO: 7

DISABILITY: Y NO X
Tick block with X)e if yes, describe the nature of disability ____________________________
s
E
_______________________________________________________________________________________________
S
RACE: (Tick block with X) African X Coloured Indian White

SECTION B

2. STUDY PROGRAMME FOR THE NEXT ACADEMIC YEAR:

MBCHB
Name of Degree / Diploma (Full name): ______________________________________________________________

Name of Tertiary Institution: University / University of Technology / TVET College applied to or registered with

Texile american University (in zambia)

(Full name): ____________________________________________________________________________________
Level/Year of Study in 2022:
(Tick block with an X)
X Year
1st Year Year 4 2nd 3rd th
Year 5th Year 6th Year
Year

SIGNATURE OF APPLICANT:_____________________________ DATE:____________________

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SECTION C
3. FAMILY FINANCIAL INFORMATION

Mark your (parents/s) father’s; mother’s; guardian’s monthly income group: (Tick block with X)

Father 0 - 250 251 -500 501-1000 1001- 2001 – 5001- 10000 +

2000 5000 10000
Mother 0-250 251-500 501-1000 1001- 2001- 5001 - 10000+
2000 5000 X 10000
Guardian 0-250 251-500 501-1000 1001- 2001- 5001- 10000+
2000 5000 10000
ATTACH PROOF OF PARENT /S’ & GUARDIAN INCOME DOCUMENT/S: SALARY PAYSLIP/S (Compulsory) (NB. In case of Deceased
parent/s also attach copy of Death Certificate/s).

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Number of people in the household :………………………………………………( Total number including parents)
3
How many dependents are still at home?........................................................
1
Number of dependents at tertiary institution:.................................................
3
Number of dependents still at school:...............................................................

SECTION D
4. OPEN ENDED QUESTIONS (Very, very important): Tick one block only.
Please indicate the extent, to which you agree with each statement by ticking (X) to the statement,
remember to think only about your real reactions when answering, rather than desired reactions.

1. Why did you choose this field of study?

Prestige
Passion X
Money
No other Choice

2. How do you plan to use your skills & knowledge after graduating?
Make an impact in the society X
Get employment and improve my life
Empower others by sharing my skills
Uncertain

3. If you become the first person in the area where you live or any area (within the North
West Province) to qualify in the field of study you have chosen, what are the changes that
you could make in your community?
Provide a better support for young people's positive development X
Focus on developing rural communities.
Financially assisting one or more students to further their studies
Uncertain
4. Give reasons why you would make such changes as mentioned in question 3 above?
Develop a sense of mattering
To gain respectful status
To see change X
No idea
SECTION E

DECLARATION BY THE APPLICANT:

I declare that the information stated above is to the best of my knowledge, true and correct and I understand
the conditions governing the grant of the bursary by the North West Provincial Government that any false
information will automatically disqualify me from obtaining a bursary. By signing this application form, I accept
and understand that this bursary application does not guarantee that I will receive a bursary. If I am not
successful, I will be fully responsible for all the required fees by the university/college.

SIGNATURE OF APPLICANT:_____________________________ DATE:____________________