IMA Bursary Application Form

Failure to complete this application form fully and correctly may prejudice the applicant’s chances of obtaining a bursary.

Bursary Application

"*" indicates required fields

Personal Particulars

First Name*

Surname*

Identity Number*

Date Of Birth*

Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Tel. No*

Fax. No

Mobile No.*

Alternate Contact Number

Email Address*

Nationality*

Marital Status*

Single

Married

Divorced

Widowed

Gender

Male

Female

Race

Are you currently employed?

If Yes, Please elaborate

If employed, please elaborate

Number of Siblings

Name

Age

Occupation

Have you ever been convicted of a criminal offence, dismissed from employment or requested to resign?

If Yes, Please elaborate

Please elaborate

Did you consult a vocational counsellor regarding your choice of study?

Have you previously received an IMA bursary?

Have you applied for any other bursary?

If yes – which year and for how long?

Name of Diploma/Degree/Certificate

Are/were you in possession of another bursary/scholarship?

If the answer is yes please indicate the name of the donor and amount:

Obligations attached to bursary/scholarship:

Name of the degree/ diploma/Certificate which you are applying for

What will the major subjects be for the degree or diploma?

Number of years you intend studying for:

Name of tertiary institution you intend studying at

Qualifications

Highest standard passed

Name of school attended

Town/city

University and/or other post school training/studies

Are you presently enrolled at a tertiary institution/college?

Name of institution/college

Current year of study

Name of degree/diploma

Please indicate the year you started studying for the current course of studies:

List the subjects that still need to be completed to obtain the relevant qualification:

Have you ever failed any year of study?

If yes, Which year?

Have you rewritten the examination/s for the subject/s failed? If yes, please indicate the date of the examination

Student number at current institution

Parent / Gaurdian

Name

First Last

Phone

Address of parent/legal guardian

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer of parent/legal guardian

Declaration*

I declare that the information provided is true and correct.

I understand that this application for a bursary is not a loan and declare that the above particulars are complete and correct.
Bursaries will be considered for health sciences studies that are registered with a recognised association, such as Health Professionals Council of South Africa (HPCSA); South African Health Products Regulatory Authority (SAHPRA); South African Council for Social Service Professions (SACSSP); South African Veterinary Council (SAVC), or any registered body not mentioned here, pertaining to Health Sciences.
It is compulsory to declare any other grant, scholarships, bursaries or applications being made presently or in the future.

STUDY PLAN:

Name

Full Name ID No.

Education

Institution Name of Qualification

Agreement*

I propose to study for the above qualification as follows: Courses Subject/Course Name Course Code Year to be taken.

Attach copy of syllabus

Max. file size: 64 MB.

Name

Full Name Date

Details Of Monthly Income And Expenditure

Details

Name Of Parent/Gaurdian Income: Self Income: Partner Income: Additional Total Nett Income

Rental Of House/Flat

Electricity

Telephone

Domestic Wages

Groceries

Transport Expenses

Educational Expenses

Medical Expenses

Vehicle, Furniture & Clothing Accounts Amount

Name

Amount

Any Other Accounts (Please Specify, Including Anticipated Date That Debt Will Be Finalised):

Name

Amount

Completion Date

Total Expenses (in Rands)

Declaration

I declare that the information provided is true and correct.

Name

Full Name Date

Required Uploads

File

Max. file size: 64 MB.

A certified copy of an official statement of results as well as official proof of matriculation.

File

Max. file size: 64 MB.

A certified copy of your official study record showing marks, symbols, percentages obtained in all examinations written (including the matriculation examination)

File

Max. file size: 64 MB.

A certified copy of your identity document.

File

Max. file size: 64 MB.

Copy of the admission requirements from the academic institution for the intended course of study if you have not already been accepted.

File

Max. file size: 64 MB.

Document from the academic institution of the tuition fees that will be required.

File

Max. file size: 64 MB.

Proof of income must be provided or a letter from the Department of Labour or an affidavit from parent/s stating that they are unemployed.

File

Max. file size: 64 MB.

Originally certified death certificate/s of parent/s. (If applicable)

File

Max. file size: 64 MB.

Letter of motivation (explain why you believe you are deserving of a bursary outlining your circumstances).

File

Max. file size: 64 MB.

Proof of your NSFAS Application and outcome.

File

Max. file size: 64 MB.

Parent/s – 3 month payslips and bank statements.

Consent

I agree to the privacy policy.

I do hereby give my consent, to IMASA, to process my personal information as follows:

My contact details including my email address, cell no, work no, physical & postal, HPCSA no etc, to receive relevant information in relation to CPD accredited programmes and other events / project information at IMASA block

Adding me to regional and national whatsapp groups block

Providing my details to sponsors and other third parties who may on occassion require my information block

Providing my details to sponsors and other third parties who may on occassion require my services etc block

in accordance with the provisions of the Protection of Personal Information Act.

Only successful applicants will be contacted for a bursary
The committee will not give reasons for declining the bursary application