GOVERNMENT OF SAINT LUCIA STIPEND APPLICATION FORM. 1=:=<1020: SECTION A: PERSONAL INFORMATION NAME: TAST NAME FIRST NAME ‘OTHER NAMES DATE OF BIRTH. NATIONALITY: MALE FEMALE MMDDYY HOME ADDRESS: APTWSTREET MAILING ADDRESS: P.O BOXPOST OFFICE TOWNIVILLAGE POSTAL CODE CONTACT NUMBERS: HOME WORK MOBILE EMAIL ADDRESS: NEXT OF KIN: RELATIONSHIP OF NEXT OF KIN: CONTACT OF NEXT OF KIN: HOME WORK, MOBILE SECTION B: ENROLLMENT INFORMATION 1. ARE YOU CURRENTLY ENROLLED IN A BACHELORS DEGREE PROGRAMME AT SIR ARTHUR LEWIS, COMMUNITY COLLEGE YES. NO IF YES, PLEASE INDICATE WITH A TICK (), WHICH OF THE FOLLOWING PROGRAMMES: SIR ARTHUR LEWIS COMMUNITY COLLEGE — DIVISION OF TEACHER EDUCATION AND EDUCATIONAL ADMINISTRATION (SALCC-DTEEA) SIR ARTHUR LEWIS COMMUNITY COLLEGE ~ DEPARTMENT OF HEALTH SCIENCES (DHS) ~ NURSING PROGRAMME. IF NO, MOVE TO QUESTION TWO (2) 2. DID YOU SUBMIT AN APPLICATION FOR ENTRY INTO A BACHELORS DEGREE PROGRAMME AT SIR ARTHUR LEWIS COMMUNITY COLLEGE? YES| Ne) IF YES, PLEASE INDICATE WITH A TICK (), WHICH OF THE FOLLOWING PROGRAMMES. SIR ARTHUR LEWIS COMMUNITY COLLEGE — DIVISION OF TEACHER EDUCATION AND EDUCATIONAL ADMINISTRATION (SALCC-DTEEA) SIR ARTHUR LEWIS COMMUNITY COLLEGE ~ DEPARTMENT OF HEALTH SCIENCES (DHS) = NURSING PROGRAMME,SECTION ¢: FINANCIAL NEEDS ASSESSMENT 1. ARE YOU CURRENTLY A RECIPIENT OF A SCHOLARSHIP/FINANCIAL ASSISTANCE? YES IF YES, PLEASE STATE THE INSTITUTION/AGENCY AND AMOUNT RECEIVED, 2, HAVE YOU APPLIED FOR A SCHOLAI INSTITUTION/AGENCY? ‘YES IF YES, PLEASE STATE THE INSTITUTION/AGENCY __ 3, HAVE YOU EVER BEEN A RECIPI YES IF YES, PLEASE STATE THE INSTITUTION/AGENCY NO NO NO 4, PLEASE INDICATE THE TYPE OF FAMILY YOU CURRENTLY RESIDE WITH. NUCLEAR 3. INDICATE THE TYPE OF DWELLING IN WHICH YOUR FAMILY RESIDES. RENTED FAMILY-OWNED |SINGLE-PARENT OTHER > PLEASE GIVE DETAILS:_ OWNED > IS THE PROPERTY MORTGAGED? RSHIP/FINANCIAL ASSISTANCE WITH ANY OTHER ENT OF A SCHOLARSHIP/FINANCIAL ASSISTANCE? EXTENDED LIVE ALONE YES Xe} 6. PROVIDE DETAILS OF VOLUNTARY, SOCIAL, COMMUNITY OR SPORTING ACTIVITIES IDECLARE THAT THE INFORMATION PROVIDED ABOVE IS ACCURATE AND TRUE. APPLICANT * Applicants will be contacted for a telephone interview if necessary. DATEJ FOR OFFICIAL USE ONLY COMMENTS Officer's Name: Officer's Signature: Date : NOTE: > THE FOLLOWING DOCUMENTS MUST BE ATTACHED TO THIS APPLICATION FORM COPY OF BIRTH CERTIFICATE/ PROOF OF SAINT LUCIAN CITIZENSHIP COPIES OF TRANSCRIPTS (Applicants already enrolled in a programme) COPIES OF SALARY SLIPS OR JOB LETTER (WHERE APPLICABLE) LETTER OF ACCEPTANCE (IF AVAILABLE) TWO (2) RECOMMENDATION LETTERS FINANCIAL NEED ASSESSMENT FORMMINISTRY OF EDUCATION, INNOVATION, GENDER RELATIONS AND SUSTAINABLE DEVELOPMENT (Human Resource Development Unit) FINANCIAL NEEDS ASSESSMENT NAME OF COURSE. NAME OF APPLICANT DATE OF BIRTH .. SEX:MaleQ Female 0 ADDRESS: (Home) ADDRESS: (Mailing) TELPHONE NO. Contact No.: EAMILLINEORMATION (persons in-yout houschold) ‘NAME ‘OCCUPATION MONTHLY | Salary/Wages PERSONAL FATHER MOTHER SPOUSE GUARDIAN Please provide evidence e.g. pay/salary slip or job letter. List of names of OTHER persons in your household. Please indicate whether they are employed, unemployed or student. NAME AGE RELATIONSHIP EMPLOYMENT STATUS | Employed/Unemployed/Student Important: All sections of this form must be completed.Residential Status: { } Rental Monthly Rent : (please provide evidence) { } Owned { } Mortgage Monthly Payment { } Other (please specify) Do you receive help from other sources? Yes No @ If yes, please specify: ‘Are there any members of your family currently on scholarship at a university? O Yes No If yes, what is the source of funding? Q Loans Grants Personal Funds 1 Others (please specify) How would the balance of fees be financed? Q Student Loan Q Family/Personal Funds Grant ‘What Collateral is available to you? O House Land O House/Land O Trust Fund O Other (please specify) .... Are you actively involved in Community Activities? Sports Q Youth Organizations O Religious Q Other (please Specify) ....... I declare that the information provided above is accurate. Signature of Applicant | Signature of Parent/Guardian Date Important: All sections ofthis form must be completed.