environmental affairs Department: Environmental Affairs REPUBLIC OF SOUTH AFRICA

DEA APPLICATION FORM

FULL· TIME BURSARIES

INSTRUCTIONS REGARDING THIS BURSARY APPLICATION FORM:

• It is not for DEA staff members • Closing date for the bursary applications will be stated on the advert

• Use block letters to complete the application form • Give concise answers and where applicable mark with X

• Attach certified copies as indicated in section H • Provide detailed motivation on section G • Incomplete or late applications will not be considered

• Applications can be forwarded to : The Director General Private Bag X 447 Pretoria 0001

For attention: Learning and Development- Bursary Section

• How did you hear about the DEA bursaries?

Newspaper University Friends Internet staff

Career Other, Awareness specify

A. PARTICULARS OF THE APPLICANT

Title: ... ... ... ..... ... ..... ... 0 0000 0 00 Surname: 00 0 0 0 0 0 . 0 0 0 0 0 0 0 .. 0 0 0 0 0 0 0 0000 0 0 0000 0000 00 0 0 0 0 0 0 0 0 0 0 0 000 0 0 0 0000 00 0 0 0 0 0 0 .. o 00 0 0 . 0 0 0 0 0 00 00. 0 0 0 0 0 0 0 . 0 0 0 0 00 0 0 0 0 00. 0 0000 000 0 000

First Names: o ooooooooooooOOO o ooooo 00 o oo oo oo 0 0 0000 .0000 00 00 0 0000000 oo oo o ooooo oo o o o oo oooooooooooooooooooooo 000000000 00 0 00000000 00 0000 00000 00000000000000 000000 0 0 00 00000 000 0

Gender:

j Male j Female

Identity Number:

I

Race:

j African / Coloured 'Indian j White

Nationality: 00 00. 0 0 0 0 00 0 00 0 0 0 . 00 0 0 00 00 00 00 0 0 0 0 0 0 0 0 0 0 0 00 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 00 0 00 00 00 .. 00 00 0 0 0 00 0 . 0 0 0 0 0 0 0 . 00 00 0 .. 0 0 0 0. 0 00 00 0 . 0 • • 0 0 0 00 .. 0 0 0 0 0 0 0. 0 0 0 0 0 0 00 .. 00 0 0 0 0 .. 0 0 0 .. 0 ..

Province: ooooooo o o ooo ooo o o ooooooo o ooooooooooo o ooooooo oooo ooooooooooo o oooooooo o ............ o oo ooooooooooooooooo oOOoo oo oo ooooooooooOOo oOOOooo Oo ooooooooooo o oo ...... o .. ooooo o oo

Do you have a disability?

j Yes j No

Marital Status: oo oooooo oo oo oo oo ooooo .... ........ ...... ooooooo ooooooooooo oooooooo Home Language: OOooOOOO OOOO OO OO OO oOoo OOOO OO OOOOooOOOOOO ooOOOOOOOOOOOOooOOOO

Postal Address: Residential Address:

Postal Code: oooo o o o .. . oo •• o .. oooooooooooooooooo o ooooooo oo oo oooo oo Postal Code: ooooooo oo oooooooooo oo ooo ooooooooo oo ooooooooo oooo oooo oo o ooooooooo

Cell phone No: oooooo oo o oo oooo o ooooooooooooooooooooooo oooooooooooo

Telephone No: (h) (o oo oo oo oooooooo oooooo)o .. ooOOooOOo oooooooooooooooooooo oooooooooo oo ooooo o oooo o oooo o oo o o ooooo o oooooo oo o ooooooo o .. .... ooo,ooo o oo oo ooooooo ooooooooo oo

Telephone No: (w) (oooooo ooo o o oooo . .. oo )o oo oo oooooooo o ooooooo o oooo o oo o oooo oo oo o oooo ooooooo ooOOooo o oo o ooOo oooo oooooooooooooooooo o oooooo o o ooooo ooo ooooo ooooo oooooooo

Fax No: (ooo o ooooooooo oooo o) oooooo o oooooo oooooooooooooo o ooo o o oooo o ooo .......... o.oo o oooooooooo .......... oo o ooooooo ooooooooooooooooo o ooo o oo oo o .... .. .... o o oo oo oo oooo oo oo oooo o

Email: ooo o oooo o oooooooooooooo o o ooo ooo oooo oo oo oooooooooooooooooooooooooooooooooooooooooooooooooooooo o oo oo o ooooooo ooooo oooo ••ooooooooooooooo oo o o ooooooooo ooooo ooo oo o oooo ooooo

B. PARTICULARS OF CURRENT STUDIES FOR WHICH YOU WISH TO RECEIVE A BURSARY

DIPLOMA B·TECH HONOURS MASTERS DOCTRATE

Student Number: .......... .... .... ............... ... .......................................................... ...... ... .. ....... .. ..... ..... ............. ..... .. .... .. .

At which institution are you studying? ................................................................................. .... ... ........ ...... .... ..... ........ .

Name of the Qualification ........... .. ............................................................................................................................ .

Major I main subjects .......................................... .. .. .. ............................................... ................................................. .

Mark the academic year for which you are applying for:

2 3 4

Short description or title of the proposed research projects (applicable to honours and masters)

Details of the research proposal. Indicate the problem statement and the importance of your study (research) to society. (applicable to honours and masters)

C. EDUCATIONAL QUALIFICATIONS

Name of Qualification Year of Year Full-time I Name of institution first obtained Part-time registration

NB: CERTIFIED COPIES OF ACADEMIC RECORDS OR CERTIFICATES MUST BE ATTACHED FOR ALL QUALIFICATIONS LISTED ABOVE.

If you are not currently enrolled at any educational institution, please indicate what you are doing at present.

I D. OTHER BURSARIES, SPONSORS AND DONORS

Do you presently study with a bursary? I Yes I No

If yes, what is the name of the burs~ry? .. ......... ...... .. .. .. .. ........ .. .... ................. .................................. ..... ............. ....... .

Annual value of the bursary .... ........ ........... ............. .. ........... .... ........................... .. .. .... .. ....... ............... .. .. .......... ...... ... .

Father's occupation ... ..... ... ..... ......... .............. ......... ................ .. .... ........... ................ ............. .. ............................ ....... .

Mother's occupation ..... ............................. ..... ......... ..... ..... .. ... ............... ...... ............ ........... .. ............... ....... ....... ..... ... .

Guardian's occupation ...... ... .. ..................... ..... ............... ........... .. ... ... .. .. .... ......... ...... .... ............................... ... .... .. ... ..

Mark your father's monthly income group:

I <R2 500 I R2 501- R5 000

Mark your mother's monthly income group:

I <R2 500 I R2 501- R5 000

Mark your guardian's monthly income group:

I <R2 500 I R2 501- R5 000

I >R5 000

I >R5 000

I >R5 000

Attach a proof of income or a sworn affidavit

How many other dependants are still at home? ........................ ........ .. .......... .. .......... ................................ ...... .. ....... ..

Number of dependants at tertiary institution .......... ............ ......... ...... ..... .......... .... .... .. ....... ......... ......... ................ ... ... ..

Number of dependants still at school .... ............. .. .... ........................................... .. ... ............... .. ............ ...... ....... ...... .

Do you have or have received a study loan? I Yes

If yes, name of loan ........ ..... ..... .. ............. ........ ................ ....................... ................ ... ............. ........... ...... .. ... ..... ... .... ..

For what purpose? ..... ......... ............. ............ ... ................... .. .... ........... ................. ..... ...... ..... .... .. ....... ............ ..... .... ... .

When did you get it? ... .... .. .. ... .... ..... .... ... .. ...... .... .. ....................... .... .. ................ .... .......... .... .... ............... ... .... ...... .. .... .

For how long are you intending to use it? ...... ............... ....... .. .......... .. ......... ...... ..... .... ...... ...................... .. ... .... ........ ..

E. RESEARCH EXPERIENCE AND OUTPUT

List all scientific articles/ papers have published and/ or presented and the name of the journal or conference where the article was published or was presented.

Article title ... ... .. .... ........ ... ........... : .... ....... .......... .... .... .. ..... .. ..... ............ ... ... ......... ...... ...... ........................... .... ..... ...... .... .

Authors ........ ........................ ... ............................... ... .. ..... ... .. ... ...... ... ... .... ........... .. .................... ... ..... .. ................ .. ...... .

Journal names I conference name ........ .. .. .... .... .. .. .. .. ...... .. .. .. .................... .. Date published I presented .... .............. .. .

Article title ... .... ..... ..... ....... .. ..... .... ..... .... .. .. ......... .... ......... ............ .. .... ...... ..... ....... ..... ...... .. .. ... ..... .................. ... ........... .. .

Authors ............ ... .... ... ..... .......... ... ... ....... .. .... .. ... .. .. .. ... ...... ...... ... .. ..... ... .. ........................ .......... ............... .. ......... ...... .... .

Journal names I conference name .. .. .. ............................................. ......... .. Date published I presented ............ .. .. .... .

F. DETAILS ABOUT PARENTS I GUARDIAN I NEXT OF KIN

Title: ....... .... ............. ................ ...... .. ........... . Surname: ....... .......... ........... .. ....... ...... ... ... .. ..... ................. . .

Initials: ...................... ..... ... ... .... ..... ... ............ .

Identity Number:

Relationship: .. ......... ..... .... ...... .. ... ..... ..... ... .... .. .. ............. ............ ... ....... ......... ... .. .. .... .. .. ... .......... .. ..... ....................... ..

Postal Address: Residential Address:

Postal Code: .... .... .. .... .. ............. .. .... .. .............. .. Postal Code: ..... ......... ......... .............. .. .... ............ ..... ... .

Cell phone No: .. ................... ............ .... ............ ..

Telephone No: (h)(. .. .. .... .. . ) .. ................ .. .. ...... .. Telephone No: (w) (. .......... ..... ) .............. .. .... ..................... .

Fax No: ( .......... .. .. ) .... .. ........ ........... .. ....... .. ...... .. . Email: .... .... ... .. ........ ... ... ... .... .. .. ......... .... ... ......... ... ... ... ... .. .. ..

G. MOTIVATION WHY MUST YOU BE CONSIDERED FOR THE BURSARY

/H. DOCUMENTATION

Please attach the certified copies of the following:

• Identity document • Copies of qualifications or certificates

• Recent academic records • Confirmation of registration if already registered with institution of higher learning

• Family income if parents are employed or affidavit if not employed • Admission letter • Research proposal (applicable to honours and masters)

Kindly note that successful candidates will be expected to sign a bursary contract.

I. DECLARATION

I hereby declare that the information provided in this application is true and correct in every respect. I am aware that failure to render correct information will lead to my application being disqualified. Therefore should I be awarded the bursary, I will abide by the regulations applicable.

Signature of applicant: Date:

o o o o o o o o o o o o o 0 o o o oo o o 00 o o o o o ~ o " o o o o o o o o o o o 0 o I 00 o o o o 0 o o I o o o o o o o

If still a minor, signature of the parent or guardian Date: