Official use only

Please attach two (2)

Passport size photos
“A” Level Intake ……………

2010 LOWER SIXTH SCHOLARSHIP APPLICATION FORM

1.0 PERSONAL INFORMATION

1.1 Surname / Family Name............................................................................................................

1.2 First Names................................................................................................................................
1.3 Contact Address ........................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
1.4 Telephone Number: Home ………………….. Mobile ........................................................
Work [if applicable] .............................................................................
Email......................................................................................................

D D M M Y Y Y Y
1.6 Date of birth [Attach certified copy of Birth Certificate]

1.7 Gender: [Tick as appropriate] Male Female

1.8 Nationality ................................................................................................................................
1.9 National ID No.[Attach certified copy]....................................................................................
1.10 Passport No [if available] ........................................................................................................
1.11 Religion [if any] .......................................................................................................................
1.12 Name of your Pastor/Minister [if applicable] .........................................................................
............................................................................................................................................................
1.13 Church Address [if any] ...........................................................................................................
............................................................................................................................................................
............................................................................................................................................................
1.14 Pastor`s/Minister`s Contact No .................................................................................................
............................................................................................................................................................
2.0 ACADEMIC INFORMATION

2.1 Name and Address of ‘O’ Level School….……..………………………………………

….…………………………………..…………………………………………………….
2.2 Name of School Head……………………………………………………………………..
2.3 Contact No. of School Head………………………………………………………………
2.4 Province in which “O” Level School is located …………………………………………
2.5 ‘O’ Level Exam Results [Attach Results Slips]

SUBJECT GRADE MONTH & PUBLIC EXAM

OBTAINED YEAR [e.g ZIMSEC,
ATTAINED CAMBRIDGE]

2.5.1 ………………...…………… ……….. ………………. ………………….

2.5.2 …………………….……….. ……….. ………………. ………………….
2.5.3 ……………………………... ……….. ………………. ………………….
2.5.4 ……………………………... ……….. ………………. ………………….
2.5.5 ……………………………... ……….. ………………. ………………….
2.5.6 ………………...…………… ……….. ………………. ………………….
2.5.7 …………………….……….. ……….. ………………. ………………….
2.5.8 ……………………………... ……….. ………………. ………………….
2.5.9 ……………………………... ……….. ………………. ………………….
2.5.10…………………………….. ……….. ………………. ………………….
2.5.11….……………...………….. ……….. ………………. ………………….
2.5.12……………………….……. ……….. ………………. ………………….
2.5.13…………………………….. ……….. ………………. ………………….
2.5.14…………………………….. ……….. ………………. ………………….
TOTAL “A” GRADE PASSES

2.6 Extracurricular Activities you did at “O” Level?

2.6.1…………………………………….……………………………………………...
2.6.2…….……………………………………………………………………………...
2.6.3…………………………………….……………………………………………...
2.6.4…….……………………………………………………………………………...
2.7 What positions of responsibility did you hold at this school?
2.7.1………………………………………………………………………………...
2.7.2………………………………………………………………………………...
2.7.3………………………………………………………………………………...
2
 2.7.4………………………………………………………………………………...
3.0 COMMUNITY BUILDING ACTIVITIES

List any community building/helping activities you have engaged in so far.

ACTIVITY DATES RESPONSIBILITIES

3.1 ............................................................ ................... .......................................................

..................................................................
3.2 ............................................................
..................................................................
3.3 ............................................................
..................................................................
................... .......................................................
................... .......................................................
................... .......................................................
................... .......................................................
................... .......................................................

4.0 LOWER SIXTH STUDIES

4.1 To which “A” Level School have you applied/been admitted? ..........................................
..............................................................................................................................................
4.2 Which Subjects are you studying?
4.2.1......................................................................................................................................
4.2.2......................................................................................................................................
4.2.3......................................................................................................................................
4.2.4......................................................................................................................................
4.2.5......................................................................................................................................
4.3 As a Boarder or Day Student? ............................................................................................

5.0 FINANCES

5.1 How much are the Tuition Fees this

term? ....................................................................................
5.2 How much are the boarding fees this term [where applicable]?...…………………………
5.3 How much is the levy this term?……………………………………………………………
5.4 Have you applied to other Trusts/Organisations for funding?....………………..………….
5.5 If Yes, please state the names of the Trusts/Organisations.…………………..…………….
..……………………………………………………………………………..………………
5.6 Who is otherwise paying for your studies?.………………………………..……………….
..……………………………………………………………………………..………………
3
6.0 PERSONAL STATEMENT

Explain below, and in detail, how you intend your studies at your present school to eventually
benefit your community, society or nation. What role do you see yourself playing in the future of
your community, society or nation? [Use additional page if necessary].

............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
[Use additional page if necessary]

I, ……………………………………………………………………………………………………
do hereby confirm that the information I have provided above is true, bearing in mind that if it is
found to be otherwise, my application will be disqualified.

Signature:……………………………………. Date: ………………………..

PLEASE SEND THE COMPLETED FORM TO:

The General Manager
Joshua Nkomo Scholarship Fund
N0. 52 Samora Machel Avenue
HARARE
4
Cell. 0912 222 894 or 0912 222 515