1. Title:

(Mr, Miss, Mrs, Dr)

2. Surname:

3. First Names:

4. ID number:

5. Date of birth:

6. Gender

* Male        /   Female

7. Highest level of Education:

8. Contact details:

* Home address  /  Home address of other person (if applicable):

(State below the address where the learner who needs assistance live and to which mail may be sent. If he or she does not have an address, state the address of another person who can be contacted, e.g. place of worship, school, community leader, etc.)

* Postal address  /  Postal address of other person (if applicable):

Telephone Numbers:

Home: (        )

Work: (        )

Cell no:

Complete this part only if the person who needs further assistance has received any form of assistance from the State, including NSFAS or an institution contemplated in the Skills Development Act or his / her employer, for the year for which assistance is now applied for: For example, a bursary or any discount or has been exempted from paying fees. Indicate here the form of assistance and the amount received.

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(Attach documents to support the above information.)

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(Indicate the physical address, in other words, where the college is situated.)

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(Please attach proof of the above information.)

If assistance is needed in respect of accommodation, complete the following:

Name of hostel / boarding home: ......................................................................................

Address of hostel / boarding home: ...................................................................................

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(Indicate the physical address, in other words, where the hostel / boarding home is situated.)

2.        Amount of boarding fees per academic year which has to be paid:

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(Attach proof of the amount payable and that the person who needs assistance, is hiring accommodation.)

If assistance is needed in respect of a device, complete the following:

(A devise which has been lost or damaged cannot be replaced – see Regulation 8A (5) and (6)).

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(Indicate the name, make, model and price of the device.)

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(If you require assistance of more than R7 000,00 to purchase a device that is mandatory for your programme, learning or training, please ensure that the motivation for the device by the head of the college on a letter head of the college is attached.)

If assistance is needed in respect of the settling of a debt, complete the following:

(Proof of the debt and the amount thereof must be attached.)

(Indicate the physical address, in other words, where the institution is situated.)

(Proof of this statement must be attached.)

If assistance is needed in respect of an assistive device, complete the following:

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(See Regulation 8B (7)(a), (b) and (c).)

(Attach proof of the amount and of the fact that the assistive device is needed)

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(Indicate the name, make, model and price of the assistive device.)

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If assistance is needed in respect of human support, complete the following:

If assistance is needed in respect of the settling of a fee debt, complete the following:

(Proof of the fee debt and the amount thereof must be attached.)

(Indicate the physical address, in other words, where the institution is situated.)

(Proof of this statement must be attached.)

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Name and surname:

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ID number:

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Signature of dedicated official

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Date of Certificate