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Section A: Personal information:
Surname *
First names: *
ID number: *
Nationality: *
Physical address: *
Postal address: *
Home Telephone: *
Work: *
Cellphone: *
Alternative contact person, Name: *
Contact number of alternative contact: *
If not a South African citizen, please indicate:
Country of birth:
Permanent Residence:
Yes No
Permit number:
Code: *
Work permit type:
Work permit number:
Driver's licence:
Code: *
For the purpose of our Employment Equity reporting,
please select the application box:
Gender:
Male Female
Disabled:
Yes No
Race:
Black White
Coloured Indian
Foreign National
Willing to relocate:
Language 1st:
Profiency:
fair good excellent
Language 2nd:
Profiency:
fair good excellent
Language 3rd:
Profiency:
fair good excellent
Section B: Academic Information:
Current Year of Study: *
Name of University where you are currently enrolled: *
Name of Qualification/Course for which you are currently enrolled:
Please attach a certified copy of your most recent academic record		 *
Are you in a university residence:
Yes No
If not, where are you staying?
Where did you hear about the AfriSam Bursary? *
Section C: Consent for Checks:
PLEASE NOTE:
In line with the company recruitment and selection policy all shortlisted candidates hereby agree to:
1. Undergo formal selection assessments
2. Undergo relevant medical examination, except HIV testing, for areas where it is an inherent requirement to furnish a medical fitness certificate as a job requirement
3. Provide consent for reference checking which will encompass:

a. Criminal record
b. Credit record
c. Verification of citizenship
4. Undergo formal selection assessments
Section D: Documents to be attached:
PLEASE NOTE:
In order for your application to be considered, the following documentation must be attached to this application form:
a. Curriculum Vitae/ Resumé
b. Motivation Letter (Include in your letter reasons for financial assistance and the chosen field of study)
c. Identity Document (certified copy) for parent and applicant
d. Matric Certificate (certified copy)
e. Official Academic Results
Section E: Declaration:
I declare that all information I have provided is correct and complete to the best of my knowledge. I also hereby give permission to AfriSam to forward any personal information that I have provided in support of this application to its information verification suppliers in order to verify my personal credentials and records.
Date: *
I, Accept: *