application form for st augustine …hesfb.go.ug/sites/default/files/files/scholarship application...

1

CAUTION: Any person or student who when filling a Scholarship Application Form, or during cross examination (interviews) knowingly makes a false statement whether in writing or orally relating to any matter concerning the request for a Scholarship shall be guilty of an offence punishable by law (Section 38 of the Higher Education Students’ Financing Act 2014)

APPLICATION FORM FOR ST AUGUSTINE

INTERNATIONAL UNIVERSITY SCHOLARSHIP

2

1. PERSONAL INFORMATION / DETAILS PERSONNELS

Your name must be written as stated or will be stated in your passport /academic

documents

Last Name

First Name

Sex: Male Female Date of Birth (dd / mm/ yy)

Course Applied for

Place of Birth

National ID No. (attach copy of your National ID)

Applicant’s Current Address (District, Sub County, Parish/ Ward, Village)

……………………………………………………………………………………………………………………………………………………..

Applicant’s Home of Origin (District, Sub County, Parish/Ward, Village)

………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………..

Marital status civil: Single Married

Name of spouse

Date of birth for the spouse:

Spouse’s current job & Professional address ……………………………………………………………………………………

3 Recent

passport Photos

of 12

Number of children:

Emergency Contact Person ……………………………………………………………………………………

Emergency Contact Relationship

……………………………………………………………………………..

Emergency Contact Telephone

…………………………………………………………………………………..

2. CONTACT ADDRESS & PARENTS’ INFORMATION

Address changes must be communicated to us without delay

Home:

Phone: Fax:

Mobile: Email(s):

Professional address:

Phone: Email:

2.0. PARENTS’ DETAILS OF THE APPLICANT

2.1 FATHER 2.1.1 Father’s Bio - Data Surname ……….…………………… First Name ….……………………. Other names……………….. Father’s Date of Birth (dd/mm/yyyy) ………………………………………………………………… 2.1.1 Is your Father Alive? (Yes / No) …………………………………

of 12

2.1.3 Father’s Contact Information (Where employed please attach father’s latest payslip and if self-employed attach proof of income e.g. Financial statement/bank statement and if deceased provide death certificate or LC1 Chairperson’s confirmation)

P.O. Box Number ……………………………………………………..

Email Address ……………………………………………………………………

Mobile Phone Number ………………………………………………………..

District …………………………………………………………..

Sub-County …………………………………………………..

Village / LC I …………………………………………………………………………………

2.1.4 Father’s Place of Origin

District ……………………………………………………………….

Sub-County …………………………………………………………….

Parish / Ward ………………………………………………………………

Village / Cell ………………………………………………………………

2.1.5 Father’s Permanent Address District …………………………………………………………..

Sub-County ………………………………………………………

Parish / Ward ………………………………………………………………

Village / Cell ……………………………………………………………………

Street / LC1 ……………………………………………………………….

Plot No. (Where applicable) …………………………………………………………..

2.1.6 Father’s Disability (Please attach a picture and Doctor’s report) Does your father have any disability? Yes / No ……………………………….. (If YES, please indicate which of the following disabilities and the extent of the disability) For each of the applicable disability, please describe its level of severity in terms of being Slight, Moderate or Severe Type of disability

1) Communicating 2) Hearing 3) Remembering 4) Seeing 5) Self- care 6) Walking 7) Others (specify) …………………………………………….

of 12

2.1.7 Father’s Highest Level of Education (Please tick appropriately)

1) None

2) Primary

3) Secondary

4) Vocational/Certificate

5) Diploma

6) Bachelor's Degree

7) Post-Graduate Diploma

8) Master's Degree

9) Doctorate Degree

2.1.8 Father’s Profession

2.1.9 Father’s Employment Information

Is your father employed? Yes / No …………………………………

(If YES, Please provide the following details)

Employer Name ………………………………………………………………….

Nature of Employers’ Business ………………………………………………………………………….

2.1.10 Father’s Income Information (monthly) * (Specify any one of the appropriate income) Income from Employment ……………………………………………………………………

Income from Business …………………………………………………………………………

Income from Agriculture…………………………………………………………………….

Income from Other Sources ………………………………………………………………………..

2.2 MOTHER (Where employed please attach mother’s latest payslip and if self-employed attach proof of income e.g. Financial statement/bank statement and if deceased provide death certificate or LC1 Chairperson’s confirmation) 2.2.1 Mother’s Bio - Data Surname ………………………………………. First Name ………………………………… Other Name(s) 2.2.2 Is your Mother’s alive? YES or NO If NO, go to 2.3

of 12

2.2.3 Mother’s Contact Information P.O. Box Number …………………………………………………………..

Email Address ………………………………………………………………

Mobile Phone Number …………………………………………………………

District ……………………………………………………………….

Sub-County ………………………………………………………………..

2.2.4 Mother’s Place of Origin

District …………………………………………………………………

County ……………………………………………………………………

Sub-County ………………………………………………………………………..

Parish / Ward ………………………………………………………………………

Village / Cell ………………………………………………………………………….

2.2.5 Mother’s Permanent Address District …………………………………………………………..

Sub-County ………………………………………………………

Parish / Ward ………………………………………………………………

Village / Cell ……………………………………………………………………

Street / LC1 ……………………………………………………………….

Plot No. (Where applicable) …………………………………………………………..

2.2.6 Mother’s Disability (Please attach a picture and Doctor’s report) Does your mother have any disability? YES / NO (If YES, please indicate which of the following disabilities and the extent of the disability) For each of the applicable disability, please describe its level of severity in terms of being Slight, Moderate or Severe Type of disability

1) Communicating 2) Hearing 3) Remembering 4) Seeing 5) Self- care 6) Walking 7) Others (specify) …………………………………………….

of 12

2.2.7 Mother’s Highest Level of Education * (Please tick appropriately) 1) None …………………………………………… 2) Primary ……………………………………. 3) Secondary …………………………. 4) Vocational/Certificate …………………….. 5) Diploma ………………………….. 6) Bachelor’s Degree ………………………. 7) Post-Graduate Diploma …………………… 8) Master's Degree ………………………… 9) Doctorate Degree ……………………………

2.2.8 Mother’s Profession

………………………………………………………………………………………………………………………… 2.2.9 Mother’s Employment Information Is your mother employed? Yes / No (If YES, please provide the following details)

Employer Name ………………………………………………..

Nature of Employers’ Business ………………………………………………………… 2.2.10 Mother’s Income Information (monthly) * (Specify any one of the appropriate income) Income from Employment ………………………………………………………………..

Income from Business ………………………………………………………………………………..

Income from Agriculture ………………………………………………………………………..

Income from Other Source ……………………………………………………………………….

2.3 Details of Siblings (for your school going siblings, please list by name, Age, School and Amount of School fees pay, in case any of them has a disability, please provide the relevant information , and in case the space provided is not adequate, complete and attach an additional sheet.)

Name Age School Amount of School fees

State if sibling is disabled

of 12

2.4 Family Social Economic Situation 2.4.1 Biological Parent Details Total number of children from biological father ……………………

Total number of children from biological mother …………………………

2.4.2 Are your parents staying together? Yes / No ……………… If NO, with whom do you stay? 2.4.3 Type of family residence (tick appropriately)

a) Rented

b) Owned

c) Employers’

d) Others (please specify) ____________________

2.4.4 Type of house

a) Permanent

b) Semi-Permanent

c) Others (please specify) _____________

2.4.5 Number of rooms in the family house ……………………………. 2.4.6 What is the estimated monthly expenditure of the household in UGX?

1. Rent ………………………………

2. Food ………………………..

3. Clothing ………………………

Utilities ………………………………

4. Water …………………………..

5. Electricity ………………………….

6. Gas …………………………..

7. Charcoal ……………………………

8. Paraffin ………………………………

9. Firewood ……………………………

10. Airtime ………………………………..

11. Pay TV ………………………….

12. Transport ………………………

Total Monthly Household Expenditure (sum of all the above): ………………………………………

of 12

4. ACADEMIC INFORMATION

A. EDUCATION BACKGROUND (attach copies of Certificates / pass slips )

Level Institution Index/Registration

number

Year of

completion

Points/grade

University

Tertiary

A’ level

O’ level

Primary

Other studies, trainings, workshops in relation to the chosen study programme

Level Institution Index/Registration

number

Year of

completion

Points/grade

University

Tertiary

A’Level

O’ level

Primary

6. WORKING EXPERIENCE AFTER YOUR SECONDARY/COLLEGE/UNIVERSITY

(Starting with your current employment)

Name and address

of Employer

Position

held

Duration of

your work

Description of your

responsibilities

of 12

8. REQUEST FOR SCHOLARSHIP

NB. This Scholarship is available at St. Augustine International University.

Requested study programme: ………………………………….

Programme duration : ………………………………………………..

STATEMENT OF MOTIVATION AND FUTURE PLAN

Describe your motivation for attending the desired study (max. 4000 characters)

Important elements are

What are the major objectives you hope to achieve?

What are the activities that you hope to develop after the study?

Please use a seperate sheet

10. ADDITIONAL INFORMATION

Any additional information that you deem useful for supporting your application

11. STATEMENT OF HONOUR / DECRALATION

I, undersigned, declare upon my honour that the statements I made in this application

are true and provided in good faith. If I am granted a scholarship, I undertake the

following:

1) Conduct myself at all times in a manner compatible with my status as a recipient

of the St Augustine International University Scholarship

2) Be a full-time student at the chosen course during the scholarship duration in

accordance with instructions of the course and the University;

3) Refrain from any commercial or lucrative activities;

4) Submit performance reports on a semester basis in accordance with the HESFB’s

requests;

5) Return to my home district upon completion of the study programme, in

accordance with the Scholarship Advert.

6) Inform HESFB of any changes in my status or availability that will affect the terms

of the scholarship;

7) To put my skills at the service of the development of my District of origin upon

termination of the studies covered by the scholarship.

8) I am also aware that if I knowingly make a false statement whether in writing or

during cross examination (interviews), relating to any matter concerened with

the request for a Scholarship, I shall be guilty of an offence punishable by law

(Section 38 of the Higher Education Students’ Financing Act 2014) and if proved

to have lied, I agree to forego the awarded Scholarship.

of 12

Signature : ______________________________

Full Name / Nom et Prénom : ______________________________

Date : ______________________________

12. CHECK LIST

A full application file consists of the following attachments

1. A complete application form duly signed by the applicant

2. A copy of the Applicant’s birth cerficate

3. A Copy of UCE, UACE and Certificate/Diploma result slips

4. A Copy of applicant's National ID and or any other ID

5. A copy of Parents’ / Guardina’s National IDs or any other ID

6. Copy of St Augustine International University admission letter.

7. Copy or Copies of death certificate(s) if orphaned or LC1 Chairperson's

Confirmation

8. Sketch map to applicant’s home of origin

9. Authorisation letter of the current employer (see template in annex 1)

10. Two letters of recommendation (both of whom should be professional

or academic)

11. Applicant to sign each and every page of this document

of 12

ANNEX 1: (WHERE APPPLICABLE)

TEMPLATE FOR CURRENT EMPLOYER’S AUTHORISATION LETTER

Name and address of Employer:

Name of the undersigned:

Position of the undersigned:

Contact details of the undersigned :

Phone: …………………………………………………………………………………….

Mobile: …………………………………………………………………………………….

Email: ………………………………………………………………………………………

Describe the applicant’s function and achievements

I, the undersigned, certify that the applicant, Mr/ Mrs/ Ms ………………………………………...

has worked for our company / organization since ………………………… and that our

company / organization has no objections against the candidate taking up a scholarship.

Name and signature

Date:

Stamp of the company – organization

application form for st augustine …hesfb.go.ug/sites/default/files/files/scholarship application...

Documents