Application Form SECTION 1—Applicant`s Personal Data SECTION

MINISTRY OF SCIENCE, TECHNOLOGY AND TERTIARY EDUCATION
ALL REQUESTED DOCUMENTS MUST BE ATTACHED
Application Form
SECTION 1—Applicant’s Personal Data
ALL QUESTIONS MUST BE COMPLETED
1.1
1.2
1.4
1.5
1.6
1.6a
1.7
1.8
1.9
1.10
1.11
1.12
1.13
Name: _________________________________________________________________________________________________
Surname
First
Middle
Title
Date of Birth (dd/mm/yy): _______ / _______ / _______
1.3 Gender:
Female
Male
Country of Birth: ____________________________ Attach copy of Birth Certificate.
Trinidad and Tobago Passport Number: ____________________________
Trinidad and Tobago National ID Number: _________________________Attach copy of Passport or National ID Card.
Address: ____________________________________________________________________________________
Town: ____________________________City:_____________________Country:__________________________
Attach Utility Bill for verification of address.
Mailing Address (if different from home address in 1.6 above):_________________________________________
_______________________________________________________________________________________________________
Telephone Contacts:
Home: _____________ Cell: ______________ Work: ____________________
Email address: _____________________________________
Marital Status:
Single
Married
Common Law
Separated
Divorced
Widowed
Employment Status:
Full-Time
Part-Time
Other (Seasonal, Casual)
Not Employed
Dependant:
Yes
No
Applicant (and spouse, where applicable)
reside together
separate residence
with parents
with relatives
If spouse is also a student, year of expected graduation ____________
SECTION 2—Institution and Programme Data
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13
2.14
Institution:
Local
Regional (Mona, Cave Hill, Bahamas etc)
Other approved with special arrangements
Institution Name: _____________________________________________________________________________
Institution Address: ___________________________________________________________________________
Town:____________________________City:_____________________Country: __________________________
Institution Telephone No. ___________________________________
Student Registration No. ____________________________________
If Caricom Institution or Distance Learning programme, please provide Registrar’s/Foreign Student Advisor’s name:
____________________________________________________________________________________
Programme Name: ____________________________________________________________________
Programme Level:
Certificate
Diploma
Advanced Diploma
Associate Degree
Bachelor’s Degree:
BA
BSc
BEd
BTech
LLB
BEng
DDS
DVM
MBBS
Other _______
Professional Qualification
Postgraduate Diploma
Master’s Degree
Doctoral Degree
Are you registering/registered as a Full Time or Part Time student?
Full Time
Part Time
Duration of Programme (calendar years):
1 year or less
2 years
3 years
4 years
5 years
6 years
Programme Year for which you are seeking assistance:
Year 1
Year II
Year III
Year IV
Year V
Year VI
Academic year of the programme for which you are seeking assistance:
______________________________ to _______________________________
Address for residence during course of study (if different to address in 1.6 above):
_____________________________________________________________________________________
Town:____________________________City:_____________________Country: __________________________
New Student
Continuing Student
Continuing students: Attach Result Slip(s) for previous year and copy of completed Continuing Registration Form.
New Students: Attach copy of Acceptance Letter and copy of completed Registration Form (stamped by TLI).
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SECTION 3—Tertiary Expenses
3.1
Fill in Table 3.1 below.
Total Cost:
All expenses related to the programme must be listed below in the Total Cost column to enable an assessment of the overall cost
of studying for the period indicated in question 2.12.
Amount Already Covered:
Indicate the amount for which you have already determined/sourced coverage in the Amount Already Covered column.
Source of Coverage:
Indicate using the appropriate letter from the following list in the Source of Coverage column in table 3.1 below:A
Bank Loan
B
USGLF or SRLF
C
Parents/Guardian
D
Personal Funds from savings or salary
E
Awards, Scholarships, Grants
F
Other (please state) _________________________________________________
G
GATE
Table 3.1
Item
Total Cost
TT$
Amount
Already
Covered TT$
Source Of
Coverage
A–G
Help
Assistance Sought
TT$
For Official Use
Amount
Approved TT$
Annual Tuition
Books
Accommodation
Airfare
Other Materials
Administrative
Expenses
Living Expenses
Other
Totals
Each entry must be accompanied with supporting documentation that is to be firmly attached to this application.
Where foreign currencies apply, indicate the foreign currency amount and the exchange rate used to determine the TT$ amount
entered in the table in the space under the item.
SECTION 4—Household Expenses
4.1
4.1.1
Number of persons in household: ________
Household Income Contributors (residing in the same location as applicant)
Table 4.1.1
Name
4.1.2
Name
Age
Occupation
Relationship to Applicant
Other Household Members
List in Table 4.1.2 below any members of the applicant’s household who are not employed, such as minors or disabled
household members.
Table 4.1.2
Age
Status
Relationship to Applicant
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4.1.3
Household Members excluding applicant pursuing tertiary education
List in Table 4.1.3 below any relevant member from Table 4.1.1 and/or 4.1.2.
Name
4.2
Institution
Table 4.1.3
Programme
Receiving Scholarship/
Bursary/Grant? Y/N
Household Income
This includes salary, scholarship or award funds, benefit payments e.g. disability, welfare etc., child support, alimony, rental
income, other investment income etc. List these in Table 4.2 below.
Name/Source
Type of Income
Annual Gross
Table 4.2
Annual Net of PAYE, For Official Use
NIS and HSc
Total:
Each entry must be accompanied by supporting documentation in the form of a pay slip, TD4, cheque stub, receipt,
bank statement etc.
4.3
Item
Household Expenditure
This includes utility payments, loans, living expenses, pension plan deductions, health plan deductions, school fees, land
& building taxes, medical supplies etc. List these in Table 4.3 below.
Table 4.3
Average Monthly Cost
Annual Cost
For Official Use
Total:
4.4
Item
Household Assets
These include property, motor vehicles, furniture, saving accounts, stocks, life insurance policies etc.
List these in Table 4.4 below.
Approximate Current Value
Table 4.4
For Official Use
Total:
3
4.5
Household Liabilities
These include mortgage loans, other loans etc. List these in Table 4.5 below.
Item
Approximate Balance Owing
Table 4.5
For Official Use
Total:
4.6
4.7
4.8
4.9
4.10
4.11
Do you/did you have any contractual obligations with respect to Scholarships/Bursaries/Loans?
__________________________________________________________________________________________________
If yes, describe the contractual obligations?
__________________________________________________________________________________________________
What arrangements have you made/will you make to fulfil existing contractual obligations?
__________________________________________________________________________________________________
References:
Name two responsible persons by whom confidential references about you can be obtained.
4.9 (i) Name:___________________________________________________________________________________________
Occupation: __________________________________________________________________________
Address:_________________________________________________________________________________________
Telephone Contacts:
Home: _____________ Cell: ______________Work: _________________
4.9 (ii) Name: __________________________________________________________________________________________
Occupation: ___________________________________________________________________________
Address:_________________________________________________________________________________________
Telephone Contacts:
Home: _____________ Cell: ______________ Work: _________________
Are you willing to personally guarantee repayment of the approved loan in accordance with the repayment provision of
Yes
No
HELP?
Reference (a parent, legal guardian or sponsor):
Name: ________________________________________________ Age: _______
Address: ____________________________________________________________________________________
Town:____________________________City:_____________________Country: __________________________
Telephone Contacts:
Home: _____________ Cell: ______________Work: __________________
Occupation:___________________________________________________________________________
Relationship to Applicant: ____________________________________________
SECTION 5—Declaration
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I declare that the information provided on this application is true and correct
I am aware that this application will be subject to a thorough review and may be selected for a detailed audit by the Funding and
Grants Administration Unit of the Ministry of Science, Technology and Tertiary Education
If selected for a detailed audit, I am committed to cooperating fully with the officers assigned to perform the audit
I am aware that on application my credit or other information provided may be used, given to, obtained, verified, shared and
exchanged with others, including credit bureaus, mortgage insurers, registries, other approved companies and other persons
with whom I have financial dealings as well as any other person, as may be permitted or required by law. I authorize any person
contacted in this regard to provide such information
I am aware that a false declaration can be subject to a fine or summary conviction.
Student’s Signature:
___________________________
Date (dd/mm/yy): _____/_____/______
(If the student is under 18 years this agreement must be signed by the Parent, Guardian or other responsible person over age
18. In signing below the Parent, Guardian or other responsible person approves all the Student’s obligations stated herein and
constitutes a guarantee of the Student’s obligations.
Parent
Guardian
Signature:___________________________
Date (dd/mm/yy): _____/_____/______
GUARANTEE
The Ministry of Science, Technology and Tertiary Education is committed to treating the above information with strict confidence.
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