B Code:

Individual Grant Application Form

(Continuing and further education leading to career development)

Please read the guidance notes carefully before completing the form

  1. Personal information

Full name______

Date of birth______Gender ______

Address______

______Postcode ______

Tel. Number(s)a) ______b) ______
E-mail address______

2.Your education(Please enter the most recent details first)

Name of School / College / University,

and Courses followed

/ From / To

3.Your academic qualifications (Please include class or grade)

Qualification

/ Details / Date(s)
GCE ‘O’ Level / GCSE
GCE AS/A Level
First Degree
Higher Degree(s)
Vocational Diploma(s)

4.Academic course you intend to follow(Please read Guidance note 4)

Name of institution______

Title of course______

Full-time / part-time______

Start date______Duration ______

Qualification offered______

Please describe your longer-term personal objectives and explain why you think that pursuing this course will help you to fulfil them. Why have chosen to take this particular course?

______

5.Costs (a) (Guidance note 5a)

Tuition fees ______Enrolment fee ______

Examination fees ______Books & materials ______

Costs (b) (Guidance note 5b)

Accommodation______

Travel______

Additional costs______

Total costs______

6.Your financial circumstances (Guidance note 6a)

Do you have a job? ______

If yes, please give details _:______

Full/Part-time (number of hours per week) ______

Wage/salary ______

Will this change during your studies? yes/noIf yes, how?

______

Do you anticipate being able to do paid work during your course?

If so, please provide details on the nature of this work, and anticipated income

______

______

How many people are there in your household? ______

Number and age of dependants, if any ______

Does anyone else contribute to your total household income (eg partner’s wage or salary/child support/lodger?)

Please give details

Please give details of your current financial situation (Guidance note 6a)

(Please note – if selected for interview you may be asked to supply evidence of your income)

Income (monthly) / £ / Expenditure (monthly) / £
Your wages / Mortgage
Rent
Other household members’ wages (please give details) / Council Tax
Lodger’s contribution
Jobseekers Allowance Employment and Support Allowance / Utility Bills
Child Support (from ex partner) or through CSA / Transport Costs
Other benefits – please specify (e.g. tax credits, child benefit, housing benefit or local housing allowance, incapacity benefit, pension, maternity pay, carer’s allowance etc) / Childcare Costs
Other / Other
Total monthly income / Total monthly expenditure

Other sources of funding (Guidance note 6b and 6c)

(a) applied for______

______

(b) already obtained______

______

Have you applied for a Harpur Trust Grant previously?______

7.Personal provision towards study costs (Guidance note 7) ______

8.Sum requested from The Harpur Trust(Guidance note 8) ______

9.Please use thespace below to provide any other information that you consider to be relevant to your application. We are particularly interested in how you believe undertaking your studies will benefit the local community, or the community at large. Will they complement our other grant giving activities? (Guidance note 9)

10.Declaration

I declare that all the information given is a full, frank and accurate disclosure of the personal and financial circumstances relevant to this application

The information provided on this form will be used to assess your application for a grant from the Harpur Trust. Should your application be successful it will become part of the record that we maintain for post course monitoring. Should your application be unsuccessful we will retain this form for three years after which it will be destroyed.

Signed ______Date ______

11.References(Guidance note 11)

Name Name

Address Address

Please ensure you have completed all sections of the form,

and enclosed the additional items requested in the guidance notes.

  • your current curriculum vitae (CV)
  • brief details from the course provider of your proposed course of study
  • additional items (see guidance notes)