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BURSARY SCHEME – APPLICATION FORM

Page 1 of 7 BURSARY SCHEME APPLICATION FORMFor South African citizens or permanent residents ONLYNote: Please read the Notes and Instructions on the last page before completing this APPLICATION Name:Please tick {!!!!} the appropriate choice:MaleFemalePlease tick {!!!!} the name of the BURSARY you are applying for:{!!!!}BRIDGING PROGRAMME BURSARY Closing date 31st JulyVOCATIONAL BURSARY Closing date 15th JuneEXTRACTIVE METALLURGY B TECH / TECHNIKONMINING ENGINEERING - TECHNIKONP lease tick {!!!!} the course you wish to study, or are studying. Indicate your first, second andthird choice by writing 1, 2, and 3 in the appropriate column.

Page 1 of 7 BURSARY SCHEME – APPLICATION FORM For South African citizens or permanent residents ONLY Note: Please read the Notes and Instructions on the last page before completing this application form.

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Transcription of BURSARY SCHEME – APPLICATION FORM

1 Page 1 of 7 BURSARY SCHEME APPLICATION FORMFor South African citizens or permanent residents ONLYNote: Please read the Notes and Instructions on the last page before completing this APPLICATION Name:Please tick {!!!!} the appropriate choice:MaleFemalePlease tick {!!!!} the name of the BURSARY you are applying for:{!!!!}BRIDGING PROGRAMME BURSARY Closing date 31st JulyVOCATIONAL BURSARY Closing date 15th JuneEXTRACTIVE METALLURGY B TECH / TECHNIKONMINING ENGINEERING - TECHNIKONP lease tick {!!!!} the course you wish to study, or are studying. Indicate your first, second andthird choice by writing 1, 2, and 3 in the appropriate column.

2 {!!!!}1, 2, 3 MINING ENGINEERINGMETALLURGY (Extractive only)ELECTRICAL ENGINEERING (Heavy current only)MECHANICAL ENGINEERINGCHEMICAL ENGINEERINGGEOLOGYCOMMERCE - ACCOUNTING MAJOR ONLY (Affirmative action applicants only)PLEASE COMPLETE ALL SECTIONS AND RETURN TO:De Beers Bursariesc/o Career Wise (Pty) Box 30632 Braamfontein2017 South AfricaTelephone: +27 11 403 0933 Facsimile:+27 11 403 0977 PLEASE GLUE APASSPORT SIZEPHOTO HEREHEAD ANDSHOULDERSPage 2 of 7 APERSONAL1. Name of present university (if applicable):2. Name of proposed university:3. Name and address of your present or lastschool: Postal code: 4.

3 Permanent home address in full: Postal code: 5. Home telephone no: Dialling code: 6. Address for future correspondence: Postal code: 7.

4 To which Education Region does your schoolbelong? 8. Person whom we can telephone to contactyou urgently:Name: Tel. No.: Dialling code: Relationship: 9. Name of parent or guardian: Occupation: Place of work: Tel.

5 No.: Dialling code: 10. Please indicate which centre is nearest to youfor interview purposes:(It may not be possible to interview you at the centreindicated)BloemfonteinJohannesburg DurbanCape TownPietersburgMmabathoThohoyandouPort ElizabethWelkom11. Place of birth: Date of birth: 12. Age in years this December: 13. Identity Number: 14.

6 Marital status: Single ( ) Married ( )15. South African citizen:YES ( ) NO ( )Permanent resident in South Africa:YES ( ) NO ( )16. Do you suffer from any chronic disorder orphysical handicap? YES ( ) NO ( )If yes, please give brief details: 17. Have you been convicted of any crime(s)?If yes, please state what crimes you havebeen convicted of: Page 3 of 7 BEDUCATION1.

7 Name of Secondary schools attended:NAME OF SCHOOLDATES ATTENDEDSTANDARD COMPLETED2. Please specify Grade 10, 11 and 12 results:SYMBOLSSUBJECTHG/SGGr 10Gr 11Gr 12 CURRENT POSITION INCLASS3. Have you completed Matric? YES ( ) NO ( ) If yes, please complete the following:Name of examination: Year of exam: Examination results:SUBJECTHG/SGSYMBOLPage 4 of 7 BEDUCATION continued4. If you are repeating some of your Matriculation examinations, please complete the following:Name of centre/school you are attending: Examination date: SUBJECTHG/SGSYMBOL5.

8 Have you undertaken any post-matric studies excluding full-time university? YES ( ) NO ( )If yes, please give details of the course you are studying at present and qualifications (if any) obtained. 6. Are you attending university? YES ( ) NO ( )If yes, please complete the following:Degree: Present year of study: Year in which you started your degree: Options you will take or will have taken in the final year.

9 * PLEASE ATTACH YOUR FULL ACADEMIC RECORD TO DATEPage 5 of 7 CACHIEVEMENTS1. Give details of all your activities at school and in the community, and your role in them:SCHOOLCOMMUNITY2. Give details of any activity (academic or otherwise) in which you have done well either at school and/oruniversity: (*Please attach a separate sheet of paper if this space is not sufficient)3. Have you had a part-time job? YES ( ) NO ( )If yes, please describe what you did and where you 6 of 7 DGENERAL1. Where did you find out about this BURSARY ?

10 Newspaper / MagazineCareer TalkUniversity HandbooksFamily / FriendsCareer ExhibitionSchool / Teacher2. Have you applied for a De Beers BURSARY previously? YES ( ) NO ( )If yes, which one was it?_____Which year did you apply? _____3. Do you have any other scholarship, BURSARY or loan? YES ( ) NO ( )If yes, please give details:Does it carry a service obligation? YES ( ) NO ( )If yes, explain obligation:4. Give details of working experience since leaving school:DateName of OrganisationStartEndRoles andResponsibilitiesReason for leaving5. Have you ever visited a mine?


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