For use by the NSFAS Head Office

[2012]
Acc. No. Bursary No.

SCHEDULE OF PARTICULARS:
For recipients of the Department of Higher Education and Training
Bursary for Students with Disabilities

Important Note INSTITUTION STAMP

Attach a certified copy of your South African Identity Document.
Please use black ink when completing the Schedule of Particulars.
Use of correcting fluids, (e.g. Tippex) will invalidate this Schedule of Particulars.
Any alterations must be countersigned by the Student and the Institution.

A. PARTICULARS OF STUDENT:

Identity Number: Date of Birth:

Surname: Title:

Maiden surname, if applicable:

First names (as reflected on ID):

Gender: Male Female

Disability: COMMUNICATION EMOTIONAL HEARING INTELLECTUAL MULTIPLE PHYSICAL SIGHT

OTHER If other please specify:

Race (for statistical purposes only): African Coloured Indian White Asian

Marital Status: Single Married Divorced Widowed

Physical Home Address (Not a P.O Box):

Code:

Postal Address (if different from home address) :

Code:

Home Telephone No (Area Code): (Number) CellPhone:

E-mail Address (Institution):

E-mail Address (Personal):

B. PARTICULARS OF ALTERNATE POINT OF CONTACT (NEXT OF KIN)

Surname: Initials: Title:

Relationship (parent, legal guardian, sibling, spouse, partner, other)

Address (if different from above):

Code:

Work Telephone No (Area Code): (Number) CellPhone:

Home Telephone No (Area Code): (Number)

C. PARTICULARS OF STUDY:

Student Number:

Course of Study (B Science, B Commerce etc. Please complete in full, no abbreviations)

Level of study (Academic level that the Student has progressed to, i.e 1st Year, 2nd Year, 3rd Year of course being studied):

D. PARTICULARS OF BURSARY:

Year to which bursary applies: 2012

D.1 Bursary Inclusions

The DHET/Disability bursary covers the cost of the following items per academic year:

Registration Fee : R

Tuition Fee: R

Prescribed text books and prescribed study notes: R

University residence Fee: R

Allowances : R

Assistive Device : R

D.2 Total Bursary Amount : R

I AGREE TO REMAIN AND WORK IN SOUTH AFRICA FOR THE SAME NUMBER OF ACADEMIC YEARS DURING WHICH I RECEIVED A BURSARY FROM
NSFAS IN ORDER TO MEET THE COSTS OF STUDYING FOR THE QUALIFICATION.

I AGREE THAT THE CONDITIONS DOCUMENT, THE SCHEDULE OF DEFINITIONS AND THE ALLOCATION TABLE ATTACHED TO THE SCHEDULE OF
PARTICULARS FORM PART OF THE AGREEMENT BETWEEN NSFAS AND MYSELF, AND MUST BE READ AS PART OF THAT AGREEMENT.

I DECLARE THAT I HAVE READ AND UNDERSTOOD THE CONTENT OF THIS SCHEDULE OF PARTICULARS AND THAT THE INFORMATION SUPPLIED
IS TRUE AND CORRECT.

SIGNED by the STUDENT at on this day of 2012

AS WITNESSES

1.

STUDENT SIGNATURE

2.

PARENT/GUARDIAN SIGNATURE*
[*Any Student under the age of majority (18) must obtain the assistance and
signature of his/her parent or legal guardian.]

For use by NSFAS Head Office

ACCEPTED on behalf of NSFAS at CAPE TOWN

this day of 2012

AS WITNESSES:
1.

2.
NATIONAL STUDENT FINANCIAL AID SCHEME: Duly authorised thereto