Northern Cape Department of Health

Human Resource Utilisation and Development

Bursary Office Attach a recent ID or
Passport size photo

RSA-CUBAN
SCHOLARSHIP APPLICATION FORM

APPLICANT’S FULL NAMES:

______________________________________________________________

The Northern Cape Department of Health intends to award RSA-Cuban Scholarship to qualifying applicants
pursuing and/ or intending to study Medicine (MBChB) in Cuba for the 2023/24 academic year intake. The
scholarship will cover tuition, accommodation, books, meals, and monthly allowance. The scholarship maily
targets those from the previously disadvantaged and/ or rural communities. Females and people with
disabilities are encouraged to apply.

INSTRUCTIONS AND GUIDELINES

1. Please complete this form in CAPITAL LETTERS using ink or a ballpoint pen.
2. Do not attach original documents. Attach certified copies only.
3. Please ensure that you attach the following documents to your application form;-
3.1 Certified copy of your Identity Document;
3.2 Certified copies of your matric results / certificate;
3.3 If already studying at an Institution of Higher Learning, a copy of previous academic results;
3.4 Acceptance letter/ Proof of Enrolment from the Institution of Higher Learning e.g. University of Pretoria;
3.5 Proof of income of parents; and
3.6 Covering letter with motivation why you want to become a medical doctor, and deserve this scholarship.

4. PLEASE NOTE:
4.1 Incomplete applications/ submitted without the required supporting documents will not be considered;
4.2 Late applications will be disqualified;
4.3 The onus is on the applicant to ensure that the required documents are submitted;
4.4 The Department of Health reserves the right to determine the total number of bursary allocations for the
academic year based on the total budget available;
4.5 Only posted or hand-delivered applications will be accepted (NO faxes and NO scanned documents);
4.6 Applications sent by fax or e-mail will not be considered;
4.7 Closing date 31 August 2023. No late, emailed nor faxed applications will be accepted
RSA-Cuban Medical Scholarship Programme
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 Northern Cape Department of Health
Human Resource Utilisation and Development
Bursary Office

5. COMPLETE ALL SECTIONS OF THIS APPLICATION FORM AND RETURN TO ADDRESS:

Post to:

Attention: Ms O. Lesejane
Director: Human Resource Utilization and Development
James Exum Building
Private Bag x 5049
Kimberley
8300

OR
Hand-deliver to:

Attention: Ms O. Lesejane
Director: Human Resource Utilization and Development
144 Du Toitspan Road
Kimberley Hospital Complex
James Exum Building
Kimberley
8301

RSA-Cuban Medical Scholarship Programme

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 Northern Cape Department of Health
Human Resource Utilisation and Development
Bursary Office

A. PERSONAL INFORMATION
1. Surname:

2. First Names:

3. Gender: Male Female 4. Title :( Mr./Ms/Miss/other

5. Nationality
6.Race: African White Indian Coloured
7.DoB D D M M Y Y 8.ID NO
9.Disability
DISTRICT X DISTRICT X
FRANCIS BAARD JOHN
10. DISTRICT PIXLEY KA SEME TAOLO GAETSEWE
ZF MGCAWU NAMAKWA
11.Town/City
12.Permanent Address 13. Postal Address

Code Code
14. Cell
Contact Home
Details Fax
email

B. FAMILY AND FINANCIAL DETAILS

15. Name of Parent/Guardian

16. Relation to Applicant
e.g. Mother, Father, Aunt etc
Occupation
Place of Work
Tel. No. Home
Work
Cell
17. Name of Parent/Guardian
18. Relation to Applicant
e.g. Mother, Father, Aunt etc
Occupation
Place of Work
Tel. No. Home
Work
Cell
19. Total Household Income
Pensioner
Mother’s Income
Father’s Income
Guardian’s Income
NB!! Certified Proof of each income must be attached

RSA-Cuban Medical Scholarship Programme

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 Northern Cape Department of Health
Human Resource Utilisation and Development
Bursary Office

C. OTHER BURSARIES OR SPONSORS

20. Are you at present Yes No
studying with a bursary?
21. If yes, name of the
bursary.
22. Annual value of the (R)
bursary

D. ACADEMIC DETAILS
23. Name of High
School
24. Grade/ Standard Completed 25.Year of Completion

26. Mid Year Result 27. Final Results

( if currently in Grade 12) (Attach proof of Grade 12/Matric results Certificate)

Learning Area Level Learning Area Level

E. TERTIARY STUDIES
28. Are you Currently registered with any institution Yes No
( if answer is No is ignore 29, 30 & 31 below)

29. Name of
Institution
30. Field of Study

31. Level of study 1st 2nd 3rd 4th Other

NB! If applicant indicates level of study above first year, prove of result should be submitted to support level of study
indicated.
No 26. Only to be completed by applicants currently in Grade 12

RSA-Cuban Medical Scholarship Programme

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 Northern Cape Department of Health
Human Resource Utilisation and Development
Bursary Office

DECLARATION

I, (name & surname of applicant) ....................................................................................... declare that

the information submitted in/ with my application form is, to the best of my knowledge, true and
correct. I agree that any incorrect or misleading information may result in adverse action taken
against me, disqualification and/ or retraction of scholarship, and immediate repayment by me of any
amounts that may be awarded to me on the basis of information provided by me in this application.

………………………………………… ………………………………….
Student’s signature Date

………………………………………… …………………………………..
Parent/ Guardian’s signature Date
(If the applicant is under 21 years of age)

RSA-Cuban Medical Scholarship Programme

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 Northern Cape Department of Health
Human Resource Utilisation and Development
Bursary Office

For Office Only

RECOMMENDATION BY THE SELECTION PANEL:
( Chairperson of the Selection Panel)
RECOMMENDED NOT RECOMMENDED

Name
Signature Date

For Office Only

RECOMMENDATION BY HRD
( Senior Manager Human Resource Utilisation and Development)
RECOMMENDED NOT RECOMMENDED

Name
Signature Date

For Office Only

APPROVAL BY HEAD OF DEPARTMENT:

APPROVED NOT APPROVED

Name
Signature Date

RSA-Cuban Medical Scholarship Programme

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