Cnr Sekame & First Street Tel: (018) 391 42784

New Office park Fax: 086 691 3438

Mafikeng, 2745 [email protected]
Private Bag X2068 www.nwhealth.gov.za
MMABATHO, 2735

NORTH WEST COLLEGE OF NURSING

BURSARY APPLICATION FORM FOR A THREE YEAR DIPLOMA IN

NURSING LEADING TO REGISTRATION AS A GENERAL NURSE (SANC
R171).

 North West College of Nursing (Mafikeng and Klerksdorp Campuses)

 SANC reference number : S- 2079 SAQA ID number :115865

Full time unemployed students only

Read the instructions & application form carefully.

Overview

The North West Department of Health invites all prospective applicants (unemployed
youth) who are South Africans and are residents of the North West Province, to apply
for a three (3) year Diploma in Nursing programme. Candidates are to apply for study
bursaries for 2021 academic year. Bursaries will be awarded to students who are
financially needy and academically performing.

Target for the College

 Applicants who are in possession of National Senior Certificates who meet the
Admission Requirements.
 Applicants who are in possession and Senior Certificate who meet the Admission
requirements.

People with Disabilities which will enable them to carry out nursing activities can apply.

The closing date for the submission of the completed application forms is
25th September 2020.

Instructions

 Only residents of the North West Province should apply.

 Complete application form in (BLOCK LETTERS) and use a black pen only.
 Section F must be duly signed by applicants or their respective parents or
guardians.
 Applicants are requested to attach the following documents to the application
form and submit directly to the respective Campuses as specified in the advert:
 Fully completed Bursary Application form with the South African Police Stamp/
Commissioner of Oaths.

Bursary Application for a three (3) year Diploma in Nursing for the 2021 Academic Year Page 1
  Proof of residence : A letter from the Tribal office or the local Municipality office
(not water statement of account)
 Certified copies of:

 South African bar-coded Identity Document/smart card;

 National Senior Certificate/ Senior Certificate;
 Copy of parent/s pay slips OR Parent/s Affidavit in case of unemployed
parent/s/guardian or pensioners’ pay slips in case of applicants without
parents, (Attach Death Certificate);
 In case of deceased parent/s; submit copy of Death certificate/s;
 People with Disability should attach Medical Certificate/s.

NB: Applications will not be considered in the following instances:

 incomplete information/documents.
 received after the closing date.
 emailed or faxed documents.
 applicants who previously benefitted from the Departmental bursary
funding.

 Your National Senior Certificate/ Senior Certificate will be subjected for

verification.
 Should it be found out that the applicant did not disclose his or her previous
bursary benefits while in the programme, his or her training will be terminated
with immediate effect and will repay all the monies spent for the period of
training at Campuses.

SECTION A

All sections are compulsory – complete all fields.

1. APPLICANT’S DETAILS

Surname : ___________________________________________________

Maiden name (if applicable):________________________________________

First name(s):____________________________________________________

Date of birth: _____________ Gender: __________ Age: ____________

ID No. : ______________________ Marital Status: _______________

Bursary Application for a three (3) year Diploma in Nursing for the 2021 Academic Year Page 2
Residential Address: ______________________________________________

___________________________________ Postal Code: _____________

Postal Address: _________________________________________________

_______________________________________Postal Code _____________

Telephone Number: (H) ___________________ Cell No: _________________

E-mail address: ___________________________________________________

District: (Tick the relevant block)

Ngaka Modiri Molema Dr. Ruth Segomotsi Mompati Bojanala Dr. Kenneth Kaunda

Sub- District: write the name of your Sub- District:

____________________

Do you have any disability? Yes No

If yes, describe the nature of disability and attach medical certificate(s)

______________________________________________________________

______________________________________________________________

Race African Coloured Indian White

Have you ever been convicted of any criminal offence?

Yes No
If yes, explain or give more details.
______________________________________________________________

Have you ever been dismissed from employment? Yes No

If yes, explain or give more details.
_____________________________________________________________

Bursary Application for a three (3) year Diploma in Nursing for the 2021 Academic Year Page 3
SECTION B

1. NEXT OF KIN’S DETAILS

Surname: _______________________ Names: ___________________________

Relationship to the applicant: _____________________

Residential address: _________________________________________________

_____________________________________ Postal Code: __________________

Postal Address: _____________________________________________________

_____________________________________Postal Code ___________________

Telephone number: ___________________ Cell number: ___________________

Fax number: ________________email address: __________________________

SECTION C

1. ACADEMIC DETAILS

National Senior Certificate Senior Certificate

Year obtained: ___________

Name of school: _____________________________________________________

Location of School: ((Tick relevant block))

Village Township Town

School Background

Physical Address of the School:

_________________________________________________________________

_________________________________________________________________

Type of School: (Tick relevant block)

Public Private

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2. INTENDED STUDY FOR THE ACADEMIC YEAR (2021):

Name of Diploma : ____________________________________________________

Name of Campus : ________________________________________

Duration of the Programme: __________________________

SECTION D

1. APPLICANT’S HOME BACKGROUND

Home location: (Insert name in the appropriate block)

Village: Farm: Township: Town:

Write the Municipal Ward Number:

Mother working : Yes No

Father working : Yes No

Guardian working: Yes No

Orphan : Yes No

2. FAMILY FINANCIAL BACKGROUND

Mark your father’s/ mother’s / guardian monthly income group: (Tick relevant block)

R <2500 R 2501 - 5000 R >5000+ Father

R <2500 R 2501 – 5000 R > 5000 + Mother
R < 2500 R 2501 - 5000 R >5000 + Guardian
Attach proof of income:
- salary advices; sworn declaration / affidavit/ (for unemployed parents / guardian)
or
- pension slip in case applicant lives with pensioner as the guardian.

NB: Attach copy of death certificate/s in case of deceased parent/s).

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How many dependants are still at home? _______________

Number of dependents still at school : ________________

Number of dependents at tertiary institution: ________________

Have you received study loan / bursary / scholarship before? : (Tick relevant block)
Yes No
If yes, name of the study loan / bursary/ scholarship:
____________________________________________________________________

____________________________________________________________________

Year obtained: _____________________________

Do you have any other qualification (s) from any educational institution?

(Tick relevant block): Yes No

If yes indicate the qualification(s) in the table below.

Name of the Qualification Year obtained Name of the Institution

SECTION E

1. Why did you choose Nursing as a career?

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

2. How do you plan to use your skills & knowledge after graduating?
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

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SECTION F

1. DECLARATION – TO BE SIGNED BY AN APPLICANT AND PARENT /

GUARDIAN IN THE PRESENCE OF A COMMISSIONER OF OATHS

I declare that the information stated above is to the best of my knowledge, true and
correct and I understand the conditions governing the granting of the bursary by the
Department of Health and if any information is found to be false or misleading in any
manner whatsoever, I will accept that as sufficient reason for disqualification without
limiting the Department to any other remedy it might deem fit.

Surname & names of the applicant: (in full)

________________________________________________

_________________________ ________________
Signature of applicant Date

Surname & names of parent / guardian if applicable: (in full)

_____________________________________________

__________________ _________________
Signature of parent / guardian Date

I certify that the deponent has acknowledged that he / she knows and understands the
contents of this declaration which was sworn before me at

__________________________________________on the ____________ day of

__________________ (month) ______________ (year)

Commissioner of oaths / Police station official stamp

___________________________________________
Commissioner of oaths / Police Officer

NB: Application forms are available from:

The North West Department of Health website
http://www.nwpg.gov.za

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