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.

2 Indicate your first, second andthird choice by writing 1, 2, and 3 in the appropriate column.{!!!!}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.

3 Name of present university (if applicable):2. Name of proposed university:3. Name and address of your present or lastschool: Postal code: 4. Permanent home address in full: Postal code: 5.

4 Home telephone no: Dialling code: 6. Address for future correspondence: Postal code: 7. To which Education Region does your schoolbelong?

5 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.

6 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.

7 Identity Number: 14. 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.

8 Have you been convicted of any crime(s)?If yes, please state what crimes you havebeen convicted of: Page 3 of 7 BEDUCATION1. 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.

9 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.

10 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.