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P O Box 10813

LINTON GRANGE

6015

Tel: 0861 113 297

Fax: 041 379 5388

Email:

Myrtle L Aron Bursary Fund

Application Form

CLOSING DATE FOR THE APPLICATION: 31 JANUARY, OF EVERY YEAR

THE BURSARY IS AVAILABLE FOR STUDENTS WHO HAVE SUCCESSFULLY COMPLETED THEIR 1ST YEAR OF A SPEECH PATHOLOGY AND AUDIOLOGY DEGREE.

PERSONAL DETAILS

SURNAME: ______

FIRST NAME: ______

GENDER: Male ______Female______

AGE: ______

DATE OF BIRTH: ______

I.D NUMBER:______

NATIONALITY______

MARITAL STATUS: ______

No OF DEPENDENTS: ______

PREVIOUSLY DISADVANTAGED GROUP: YES______NO______

DO YOU STAY: ON CAMPUS______WITH PARENTS______

WITH OWN FAMILY______OWN APARTMENT ______

HOME ADDRESS: ______

POSTAL ADDRESS: ______

______

______CODE______

TEL NO: (______) ______

CELL.NO ______

Email ADDRESS: ______

BANKING DETAILS:

NAME OF ACCOUNT HOLDER______

NAME OF BANK ______

BRANCH ______

BRANCH CODE______

ACCOUNT NUMBER ______

UNIVERSITY DETAILS

UNIVERSITY______

UNIVERSITY DEPT. TEL NO: (______) ______

PRESENT YEAR OF STUDY: ______

FIRST YEAR OF REGISTRATION AT UNIVERSITY______

HOW DID YOU HEAR ABOUT THE Myrtle L Aron Bursary Fund ?

______

ARE YOU A SASLHA STUDENT MEMBER? ______

HAVE YOU APPLIED FOR ANY OTHER BURSARY, GRANT OR LOAN? YES / NO

IF SO STATE THE NAME OF THE ORGANISATION TO WHICH YOU HAVE APPLIED: ______

WHEN DID YOU SUBMIT YOUR APPLICATION TO THEM?: ______

AMOUNT APPLIED FOR: R______

WAS YOUR APPLICATION SUCCESSFUL? YES / NO

Motivate why you believe that you deserve this award?

______

Give a brief description of yourself, your hobbies and your community involvement.

______

Matriculation details:

School: ______

Year of Matriculation: ______

Please enclose a certified copy of your matriculation certificate.

Post Matriculation details:

Describe what you have done since matriculation. Include forms of occupation, attendance at Universities, Colleges.

YEAR / NAME OF INSTITUTION / COURSE OF STUDY OR OCCUPATION

Details of subjects studied and grades obtained:

FIRST YEAR: LAST SEMESTER

SUBJECTS / GRADES

SECOND YEAR: LAST SEMESTER

SUBJECTS / GRADES

THIRD YEAR: LAST SEMESTER

SUBJECTS / GRADES

FOURTH YEAR: LAST SEMESTER

SUBJECTS / GRADES

Please enclose certified copies of the most recent certificate of your subjects and grades

Please enclose two testimonials:

1.  From any academic staff member of the department of Speech Pathology and Audiology/Communication Pathology

2.  From any other person or organization you belong to

I, ______hereby declare that all the above information is accurate. I understand that the Council’s decision is final.

Signed on this ______day of______2______

______

Signature

PLEASE DO NOT FAX THIS FORM

MAIL COMPLETED FORMS TO:

SASLHA

PO BOX 10813

LINTON GRANGE

6015