SAKATA SEED SOUTHERN AFRICA BURSARY APPLICATION FORM

Title*

Mr
Mrs
Miss

Name*

First Names Name commonly known as Surname

Ethnic Group (For equity purposes)*

SA Citizen*

Yes
No

ID Number*

Physical Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is your postal address the same as your physical address?

Yes
No

Postal Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell*

Alternative Contact Number

Email*

Home Language*

Other languages spoken*

Do you have a valid driver’s licence?*

Yes
No

Code

Have you ever received a bursary before?*

Yes
No

If yes, what was the amount of the bursary?*

State when and for which course*

What was the outcome of your studies?*

Pass
Fail

DETAILS OF PROPOSED STUDY

Which qualification are you studying for?*

At which educational institution are you enrolled?*

Type of tuition*

Correspondence
Part-time
Full-time

Estimated cost*

Semester One*

SUBJECT	ESTIMATED COST

Semester Two*

SUBJECT	ESTIMATED COST

Registration cost*

Tuition fees*

Prescribed books*

Accommodation*

Sundry: Please specify*

TOTAL ESTIMATED COSTS

Are you staying in a university residence/hostel?*

Yes
No

If so, please provide the name*

MOTIVATION FROM APPLICANT

What aspect of Agriculture interests you most?*

Upon successful completion of studies, which career/s are you most interested in following? Please list your preferred career direction/s*

Provide details of any community service you have been involved in.*

Do you work on a part-time or student basis?*

Part-time
Student

Have you ever worked before? If so, please provide details:

Have you ever been guilty of a criminal offence?*

Yes
No

If so, please explain the nature of the offence briefly*

Do you suffer from any allergies or other medical conditions?*

Yes
No

If so, please provide details:*

I hereby confirm that the above-mentioned particulars furnished by me are accurate. I further confirm that I am not under any contractual obligation to work for another Company and should my application for the bursary be successful, I will make myself available for service within the donor organization, should this be required. I consent to the Company performing any integrity checks that may be required.

ID Document*

Max. file size: 64 MB.

Academic Records*

Max. file size: 64 MB.

Proof of registration or acceptance with university

Max. file size: 64 MB.

Electronically Signed by*

Name Surname

Date