arts and culture bursary application form · annexures listed below must accompany the application...

ARTS AND CULTURE BURSARY APPLICATION FORM

For Office Use Only Reference Number Date of Receipt

Annexures listed below must accompany the application - please send only certified copies of documentation, because the annexures will not be returned to the applicant.

All questions are answered fully A certified copy of applicant’s Identity Document/Passport Certified proof of all academic qualifications A curriculum vitae of the applicant ( which includes details of the applicant’s practical experience in the arts discipline in which she/he specialises )

The written and signed references from the two ( 2 ) referees

Written proof of acceptance from the proposed study institution or tutor where the applicant will receive the training

Copies of any quotations

I have

Signed the application form

Copied this application form and kept it for my reference and sent an original copy of the application form

Provided reasons why I need the bursary

CLOSING DATE: 31 OCTOBER 2014

FIELDS OF STUDY

PLEASE MARK (1) ONE APPROPRIATE BOX WITH AN X

1. Arts Management 11. Fashion Design

2. Ceramic Design 12. Fine Art

3. Classical Music 13. Graphic Design

4. Copywriting 14. Jewellery Design

5. Creative Writing 15. Multimedia

6. Dance and Choreography 16. Music

7. Drama 17. Performing Arts

8. Photography 18. Textile Design

9. Puppetry 19. Theatre

10. Sound Engineering 20. Visual Arts

SECTION 1: PERSONAL DETAILS

1.1 Applicant’s Surname : ___________________________________________________

1.2 Applicant’s Full Names : ___________________________________________________

1.3 Title: (e.g. Mr/Ms/Miss/Dr) : ___________________________________________________

1.4 Applicant’s Identity Number : ___________________________________________________ (Attach a certified copy)

1.5 Date of Birth : _________________________________ Age: _____________

1.6 Postal Address : ___________________________________________________(Where correspondence can be sent to)

___________________________________________________

___________________________________________________________Postal Code: _______________

1.7 Physical/Residential Address : ___________________________________________________(Where applicant lives)

___________________________________________________

___________________________________________ Province: _______________________________

1.8 Telephone Numbers : ___________________________________________________(Where applicant can be reached during the day)

Cell Number : ___________________________________________________

Alternative Contact (Parent, Guardian, etc) Name : ___________________________________________________

Relationship : ___________________________________________________ Contact Details : ___________________________________________________

SECTION 2 : COURSE DETAILS

2.1 Intended course of study : ___________________________________________________ (e.g. Diploma, BA, MA )

2.2 Name of Course : ___________________________________________________ ___________________________________________________

2.3 Duration of course : ___________________________________________________

2.4 Year of study(e.g. BA 2) : ___________________________________________________ 2.5 Period for which assistance is needed (e.g. Jan-Dec 2012 ): _________________________________

2.6 Please provide certified copies of the following documents to accompany your application:

a) Proof of acceptance to study or b) Letter of invitation to the course

SECTION 3 : INSTITUTIONAL DETAILS

3.1 Name of institution/school : __________________________________________________ ___________________________________________________

3.2 Address of Institution/ School : ___________________________________________________ ___________________________________________________

3.3 Name of department : ___________________________________________________

3.4 Name of head of department : ___________________________________________________

3.5 Name and address of contact person: ___________________________________________________

___________________________________________________ ___________________________________________________ Postal code : __________ Telephone number : ____________________________________________

3.6 Previous institutions where you studied. List only 4 relevant ones. Previous Bursaries:

Name of Sponsor Course Year

SECTION 4: REFERENCES

4.1 Referees

Provide names of three (2) referees familiar with the applicant. The people can be current/recent tutors/teachers. Do not include names of family members and friends. ATTACH the WRITTEN AND SIGNED REFERENCES from referees listed below.

1. Title First name: _____________________________ Surname: _________________________

Occupation : ___________________________________________________

Postal address : ___________________________________________________

___________________________________________________ Postal Code: _______________

Telephone (Daytime) : ________________________ Fax: ______________________

I confirm that I know this artist/student and her/his work. I have read this application and I support this request for funding. I am willing to be contacted now to discuss this application.

Signature _____________________________ Date ________________________________

2. Title First name: _____________________________ Surname: ________________________

Occupation : ___________________________________________________ Postal address : ___________________________________________________ ___________________________________________________ Postal Code: _________________

Telephone (Daytime) : ____________________________ Fax: __________________

I confirm that I know this artist/student and her/his work. I have read this application and I support this request for funding. I am willing to be contacted now to discuss this application.

Signature ____________________________ Date ________________________________

4.2 Please provide 2 references, written and signed by the persons named above.

SECTION 5. FINANCES

5.1 Budget

All Costs should be reflected in South African Rand.

1. DESCRIPTION OF EXPENDITURE FOR ONE YEAR ONLY Rand per year

REGISTRATION FEE/APPLICATION FEE:COURSE FEE/STUDY FEES:BOOK FEES

TOTAL R

NB: Do not include accommodation fees and transport fees

5.2 Previous Sponsorship If you have applied for any financial assistance for the same purpose to any other source (s), please give full details;

Source of funding Amount Approved Awaiting approvalPrivate contribution

In kind e.g. booksBusiness sponsorship:Specify:

Trust/Foundations: specify

Foreign Donors: specify

Provincial Government

Local Authorities

Others:

Total Grant

5.2 Previous GAUTENG SPORT, ARTS, CULTURE AND RECREATION bursaries/sponsorships

Year Ref. No Course studied/project title AmountRRRR

5.3 Other previous source of funds

Date Name of Sponsor Amount

5.4 What is the contribution of your host institution

_______________________________________________________________________________________

5.5 Motivation for Gauteng Sport,,Arts,Culture and Recreation fundsPlease motivate for Gauteng Department of Sport, Arts, Culture and Recreation funds towards your studies and say what you need the funds for, where will the study lead to and what will be the bene-fits for you and the Gauteng Society. (If the space provided is not sufficient, please write you motiva-tion on a separate page and attach it to your application).

_______________________________________________________________________________________

5.6 Provide the institution‘s banking account details –Bursary Department (Please ensure that these are accurate)

Account Name : _________________________________________________________

Bank Name : _________________________________________________________

Branch Name : _________________________________________________________

Bank Telephone : _________________________________________________________

Branch Code : __________________ A/c Number: _________________________

SECTION 6: DECLARATION I hereby declare that all the information supplied in this application and accompanying documentation are true and accurate.

___________________________ ____________________SIGNATURE OF APPLICANT DATE

________________________________________________________PRINT NAME AND SURNAME

__________________________SIGNATURE OF PARENT/GUARDIAN (if applicant is a minor)

_________________________________________________________ ____________________PRINT NAME AND SURNAME DATE

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