2016Educational AssistanceApplication Form for Refugee studentsbelow 35 years old with valid section 24 refugee permit.

Note: Closing date for the 2016 Application is 15 September 2015 for 2016 studies.

Late applications received after the closing date will not be considered. All necessary supporing documentation such as section 24 permit, proof of admission at Government tertiary institution and progress reports must be attached to this form. Incomplete applications will not be processed.

All applications should be delivered directly to Studietrust

87 De Korte Street, 902 Heerengracht Building,

Braamfontein Johannesburg.

Tel: 011 403 1632; Email: ; Fax: 086 567 5604

INSTRUCTIONS: Parts I, II and III of the application form should be completed by the candidate in capital letters.

Application Ref. No. ______

PART I - GENERAL

1. Family Name:First Name:Other Name:

______

2. Date and place of birth (or presumed age)

______

(Country)(Town or Village)DayMonthYear

3a. Nationality or country of origin: ______

3b. Status: Refugee□ (Please attach your section 24 refugee permit)

3c. When is your permit expiring? ------

4. Marital Status: ______(single, married, divorced, widowed)

5. Religion: ______(optional)

6. Disability/Special Needs: Please indicate whether you have any disabilities (in your body)

______

______

6. Date of entry in present country of asylum: ______

Day Month Year

7a. Present address:

______

Cell Number: ------Email: ------

7b. Postal Addresse:

------

------

8. Countries in which applicant has resided since he/she left his/her country of origin: Please indicate the dates.

Country: From (Day, Month, Year):To: (Day, Month, Year)

______

______

______

9. Name of applicant’s father: ______

10 a) Dependants: Please provide names and addresses of spouse, children and/or other dependants.

Name:RelationshipAgePlace of birthCountry (present residence)

______

______

______

______

______

______

10 b) Should a scholarship be awarded, what arrangements will be made by theapplicant to ensure the subsistence of his family during his studies?

______

PART II – PREVIOUS EDUCATION

Instructions for staff: Applicants should attach photocopies of certificates and/or other documentation. If not available, please indicate under item 22 where examinations were taken, name of examining board, subjects and grade obtained.

11. a) University/Institution: Please provide name, location, period and field of study, and degrees or other academic distinctions obtained.

Name, City, Country: From ToMain course of studyDegree obtained:

______

______

______

______

11 b) Schools and other formal training or education: Please provide details of primary, junior or senior secondary school, technical school or apprenticeships.

Name, City, Country, Type:From ToCourse of studyDegree obtained:

______

______

______

______

______

______

12. Languages: Please rate as E = Excellent, G = Good, and F= Fair.

Mother tongueReadWriteSpeak

______

Other languages:

______

______

______

13. Previous employment experience: Please list all professional experience, beginning with the most recent.

From To Details

______

______

______

______

______

______

______

______

______

______

______

______

______

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PART III – PLANNED EDUCATION

14. Proposed field of study: Please provide a detailed and precise description of course to be studied. (Letter of admission from tertiary institution must be attached)

______

______

15. Length of time required to complete programme of study: ______

16 a) Has the applicant received a scholarship previously? I Yes □ No □ .

16 b) Has the applicant taken steps to obtain a scholarship through another channel? If so, please provide details.

______

17. a) Has the applicant requested admission to an institution? ___ (yes/no)

17. b) If Yes, please attached proof of admission from institution and if No, application will not be processed

______

I certify that my statements in response to the foregoing questions are true, complete and accurate to the best of my knowledge and belief and I understand that false information given in this application will affect my chances of selection and continued sponsorship.

______

Place and date Signature of applicant

PART IV – FINANCING (To be completed only by Studietrust)

20. Estimated total cost of assistance requested: Please itemize i.e. school fees, maintenance, books, etc.)

ItemCost in Local Currency

______

______

______

______Total Cost: ______

21. a) Contribution from other funding sources towards above cost (external to DAFI):

SourceAmount

______

______

______

21. b) Amount requested from DAFI: ______

22. Remarks of interviewer:

______

______

23. If the applicant has not been granted refugee status in the country of current residence, please explain:

______

24. Travel documents and/or identity documents (type, number, place and date of issuance, Issued by and valid until):

______

25. Candidate has applied for resettlement: ___ (yes/no)

______

Place and date Signature of interviewer

______

Name of interviewer Title of interviewer

Note:

All applications should be delivered directly to Studietrust

87 De Korte Street, 902 Heerengracht Building,

Braamfontein Johannesburg.

Tel: 011 403 1632; Email: ; Fax: 086 567 5604

Closing date for submitting 2016 DAFI applications is 15 September 2015.

Late applications will not be considered

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