Namibian Society of Physiotherapy

Transcription

1 P.O. Box Windhoek Namibia APPLICATION FOR BURSARY FUND: NAMBIAN SOCIETY OF PHYSIOTHERAPY Kindly take note that applications for this bursary are limited to physiotherapy students who are Namibian Citizens only. Applications will be considered in accordance with the policy and guidelines prepared from time to time by the Executive Committee of the Namibian Society of Physiotherapy. The granting of the bursary lies within the sole discretion of the said Namibian Society of Physiotherapy. Application must be completed in full and in block letters ONLY! PARTICULARS OF APPLICANT First Name(s): Surname: Maiden Name (if applicable): Marital Status: Birth Date: / /19 Birth Town: Birth Country: Nationality: (Attach copy of passport or other documentary proof of nationality) Residential Address of Applicant: Postal Address of Applicant: (at which correspondence regarding this bursary will be accepted) Contact Number(s): Tel: ( ) Fax: ( ) (C): Home Language: Page 1 of 9

2 PARTICULARS OF FATHER OF APPLICANT First Name(s): Surname: Marital Status: Birth Date: / /19 Birth Town: Birth Country: Nationality: (Attach copy of passport or other documentary proof of nationality) Residential Address: Postal Address: Contact Number(s): Tel: ( ) Fax: ( ) (C): Occupation: Name of Employer/Company: Telephone number of Employer: Gross Monthly Salary/Income: Nett Annual Income (e.g. Salary and Income form other sources): If above can not be completed, give detailed reason: Page 2 of 9

3 PARTICULARS OF MOTHER OF APPLICANT First Name(s): Surname: Marital Status: Birth Date: / /19 Birth Town: Birth Country: Nationality: (Attach copy of passport or other documentary proof of nationality) Residential Address: Postal Address: Contact Number(s): Tel: ( ) Fax: ( ) (C): Occupation: Name of Employer/Company: Telephone number of Employer: Gross Monthly Salary/Income: Nett Annual Income (e.g. Salary and Income form other sources): If above can not be completed, give detailed reason: Page 3 of 9

4 PARTICULARS OF GUARDIAN OF APPLICANT (only if applicable) First Name(s): Surname: Marital Status: Birth Date: / /19 Birth Town: Birth Country: Nationality: (Attach copy of passport or other documentary proof of nationality) Residential Address: Postal Address: Contact Number(s): Tel: ( ) Fax: ( ) (C): Occupation: Name of Employer/Company: Telephone number of Employer: Gross Monthly Salary/Income: Nett Annual Income (e.g. Salary and Income form other sources): If above can not be completed, give detailed reason: Page 4 of 9

5 PARTICULARS OF ACADEMIC QUALIFICATIONS Highest School Grade Completed: Which Year: / /20 Name of School Attended: Town: Country: Subjects, Grades & Symbols: (if grade 12 results are not available yet, supply grade 11 results) Subjects GRADES HIGCSE IGCSE A LEVEL O LEVEL SYMBOL % MARK Does your school offer any or all subjects on HIGCSE of A Level? Please specify: LANGUAGE PROFICIENCY (state whether nil, poor, fair, good or fluent) English: Speak Read Write Other(s): Speak Read Write Specify: ARE YOU CURRENTLY STUDYING PHYSIOTHERAPY? IF YES, KINDLY PROVIDE THE FOLLOWING INFORMATION: Fulltime / Part-time: Name of Academic Institution: Course Registered for: Registered student from: 23 / /20 to: / /20 Kindly attach Certified Academic Record(s) Page 5 of 9

6 ARE YOU INTENDING TO STUDY PHYSIOTHEAPY? IF YES, PLEASE COMPLETE THE FOLLOWING: Fulltime / Part-time: Name of Academic Institution: Course Registered for: Duration of Course: Have you already applied for admission to such institution(s), and if so, state its or their name(s) and attach certified proof of application thereof: Have you been admitted to such institution(s) for the following academic year, and if so, attach proof thereof: Shortly indicate career intentions after completion of studies: Do you intend to return to Namibian on completion of your studies? (If not, the bursary will have to be repaid) OTHER ACTIVITIES AND INTERESTS Tell us about yourself and why you want to study physiotherapy: Why do you think you should receive financial support? Page 6 of 9

7 ACADEMIC REFERENCES (Applicant MUST provide at least two academic references. e/g/ School master, principal) 1. Name and Surname: Address: Position or Occupation: Telephone number: ( ) 2. Name and Surname: Address: Position or Occupation: Telephone number: ( ) GENERAL REFERENCES (e.g. an adult who knows you well) Name and Surname: Address: Position or Occupation: Telephone number: ( ) PARTICULART=S OF OTHER BURSARIES Have you applied for any other bursaries, and if so, please state the names of the Institution(s) and such bursaries: Has any of these bursaries already been awarded to applicant, and if so, state name and amount of bursary: Page 7 of 9

8 PARTICULARS OF SURETY Who is prepared to bind him/herself as surety towards the Namibian Society of Physiotherapy for the applicant? Name and Surname of Surety: Occupation of Surety: Residential Address of Surety: Business Address of Surety: IMPORTANT NOTICE 1. Application forms should be completed by the applicant personally. 2. All application forms should be accompanied by certified copies of the following documents (note that the Namibian Society of Physiotherapy shall accept no responsibility of original documents). 3. Application should include the following documents: 1. certified copy of birth certificate 2. certified copy of grade 12 certificate and grade 12 results (Grade 11 if grade 12 is not available yet) 3. certified copy of official university results (if applicable) 4. certified copy of identity document/passport 4. Completed application forms should be couriered or delivered by hand to the secretary of the Namibian Society of Physiotherapy. Sonika Swiegelaar 7 Heliodoor Street, Eros, Windhoek, NAMIBIA 5. Only short listed candidates will be invited to attend an interview for purposes of their application. 6. The granting of the bursary lies within the sole discretion of the Namibian Society of Physiotherapy and their decision is final no correspondence will be entered into this regard. 7. All information will be treated as confidential and will only be used for purposes of considering your application. 8. Successful candidates will be expected to furnish the Namibian Society of Physiotherapy with proper proof of university registration, as well as their official university results at the end of each academic term. Failure to comply herewith may result in the immediate withdrawal of the Page 8 of 9

9 bursary. Any decision in the regard will lie within the sole discretion of the Namibian Society of Physiotherapy. I the undersigned declare that, to the best of my knowledge and believe, the information contained in this form is true and correct and I also acknowledge that false information invalidates this application. Signed at on this day of of 20 Signature of Applicant Assisted by: Natural Guardian/Parent (in the case of minors): 1. Signature 2. Signature Page 9 of 9