application form - cohort three academic …mcfsp.mak.ac.ug/docs/mcf application form 2016.pdf ·...
TRANSCRIPT
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Attach two copies ofrecent passport
photograph
APPLICATION FORM - COHORT THREEACADEMIC YEAR - 2016/2017
Makerere University, in partnership with The MasterCard Foundation is implementing a Scholars Program that targets academically talented yet economically disadvantaged youth of Africa to access quality undergraduate education. Only students admitted to Makerere University main campus will be considered for this scholarship. This application form is free of charge. Applicants are advised to read the application guidelines before filling in the form. After completing the form, submit to Senate Building, Level 4, Room 401 or send through email address [email protected] / [email protected] Only short listed candidates will be contacted to appear for interview. Cases of impersonation, falsification of documents, giving false/incomplete information whenever discovered will lead to automatic cancellation and/or prosecution in the Courts of Law of Uganda. The deadline for submission is 27th May, 2016.
To be filled by applicant (Incomplete applications will not be considered)
Section A. Personal Information of Applicant (As per UACE registration)
A1 Surname
A2 Other Names
A3 Date of Birth (did/mm/yyyy) (Attach a photocopy of a birth certificate )
A4 Sex Male Female
A5 Place of Birth: District Country of Birth Country of Citizenship
A6 Native Speaker/Language
A7 Current Contact Address
Village Sub-county
District of residence Country
A8 Name the nearest main road from the district town to your home/residence
Attach a sketch map of how one gets to your home/residence or draw it on page 12
A9 Give a distinctive feature to your home
A10 District of Origin if different from district of residence
B: Contact Information
B1 Applicant’s telephone number
B2 Parent/Guardian’s telephone number
B3 Mother’s telephone no
B4 Permanent email address:
MAKERERE UNIVERSITY
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B5 Facebook email address:2
School Contact Information
B6 School email address
B7 School telephone number(s)
B8 Other contact person likely to know how to reach the applicant in the future
B9 Relationship to applicant:
B10 Country of residence:
B11 Contact email address:
B12 Contact Phone(s)
Section C. Academic Information
Examination Year of undertaking this exam
School/Institution /District
Overall score or grade point
Was the school Public or Private
C1 UACE/its equivalent (Attach a photocopy result slip/certificate and Identity Card)
C2 UCE (attach a photocopy of a result slip/certificate)
C3 PLE (attach a photocopy of result slip/certificate)
C3 Amount of fees paid at each level per year
Advanced level, secondary school
Ordinary secondary school
C4 Indicate the subjects offered at A level and the grades obtained in each
Subjects Grade points Grades Obtained
1.
2.
3.
4.
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5. General Paper
Total
Section D: Socioeconomic Background D1 Status of Mother Alive Deceased Unknown Attach copies of death
certificates if applicable D2 Status of Father Alive Deceased Unknown
D3 Do you live at an orphanage or other care institution?
Yes No
D4 Who is the head of Household (Tick applicable)
a) Mother b) Father c) Guardian
d) Siblings e) Other relatives f) Guardian not
related to scholar
g) Self h) Other
D5 Specify Other D6 Gender of Head
of Household D7 Age
D8 Head of Household #1's highest level of education completed:
Primary Secondary Tertiary TVET No formal Education
D9 Head of Household #1's occupation (Tick)
Armed Forces occupation
Clerical Support workers
Crafts and Related Trades workers
Elementary occupations (laborers, street workers, street vendors etc.)
Managers
Plant and machine operators
Professionals Service and sales workers
Skilled Agricultural workers
Subsistence farmers, fishers and gatherers
Technicians and associated professionals
Don’t Know D10 Others (Specify)
D11. Occupational Status of head of household #1:
Employee - Full-Time Employment
Employee - Part-Time Employment
Self-Employed - With Employees
Self-Employed - Without Employees
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Retired - With Pension
Retired - Without Pension
Not Employed
D12. Head of Household #1's income Per Year
D13 List sources of income:
Activity Income
D14 Head of Household #2's highest level of education completed:
Primary Secondary Tertiary TVET No formal Education
D15 Head of Household #2's occupation (Tick appropriately)
Armed Forces occupation
Clerical Support workers
Crafts and Related Trades workers
Elementary occupations (laborers, street workers, street vendors etc.)
Managers
Plant and machine operators
Professionals Service and sales workers
Skilled Agricultural workers
Subsistence farmers, fishers and gatherers
Technicians and associated professionals
Don’t Know E 15 Others (Specify)
D16 Please provide compelling evidence that you are socially and economically disadvantaged and that you qualify for the scholarship. Show evidence
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Head of household #2: Specify if not same as household #1
D17. Occupational Status of head of household #2:
Employee - Full-Time Employment
Employee - Part-Time Employment
Self-Employed - With Employees
Self-Employed - Without Employees
Retired - With Pension
Retired - Without Pension
Not Employed
D18. Head of Household #2's income Per Year
D19. Which household members does the applicant live with? (check all that apply):
Mother
Father
Guardian(s)
Sibling(s) (Indicate no. of siblings)
Other Relative(s)
Friend(s)
Self
Other Please explain 'other' household member: ……………………………………………………..
D20. Which sources take care of the majority of your household expenses? (check all that apply):
Parent(s)
Guardian(s)
Self
Sibling(s)
Guardian(s) not related to scholar
Community member(s)
Government
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Other Relative(s)
Other
D21. Please specify: ……………………………………………………..
D22. Who paid for previous schooling? (check all that apply):
Employer
Guardian(s)
Guardian(s) not related to scholar
Other Relative(s)
Parent(s)
Scholarship (Attach recommendation from the sponsor)
Self
Sibling(s)
Sponsor(s)
Other
If ‘Other’, please state who paid fees ……………………………………………………..
D23. State whether you have a passport. Yes No
D24. If you have a passport, what was the purpose of your travel?
D25. Estimated household expenses at time of application (e.g. Food costs, electricity bills, rent costs):
(Per month)
D26. Number of people living in household including the applicant:
D27. Number of dependent children living in household including the applicant:
D28. Number of dependent children living in household who don’t go to school excluding applicant:
D29. State whether your household has livestock? Yes No
D30. List the livestock and state the numbers
D31. Does the household have electricity? Yes No
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D32 Does the household have a title deed? Yes No
D33. State the type of Toilet Flash and Pour VIP latrine Covered Pit latrine Uncovered Pit Latrine Composting toilet No facility /bush /field Ecosan
D34.Toilet shared with others Yes No D35. Is their running water in the household Yes No D36. Type of Roofing material D37. Type of house (permanent or semi-permanent)
D38. Type of Floor D39. Number of Rooms in the house D40. List the household assets i.e. mobile phone, TV, Radio, Bicycle, Car, Refrigerator, etc.
E: Section E: Leadership Experience
E1 Describe previously held leadership position, activities, or experiences: (i.e. positions where the scholar has guided or led a group of people, a project, or a cause):
E2 Awards and Honors received: (i.e., secondary school citizenship award; president's medal for outstanding leadership, etc.
E3 Are you good at public speaking?
E4. Participation in extracurricular activities:
Sports
Religious Groups
School Clubs
Community services
Local organizations
Peer-to-peer groups
Other
E5…Other Explain ………………………………………………………………………………… E6. If you have been a member of a team, club, organization, or association, specify your role:
Member
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Chair
Vice Chair
Secretary
Founder
Other
E7 Explain Other………………………………………………………………………………………………….
E8. If you have previous work experience, please provide a short explanation of this experience
…………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………….
Section F: Community Service Experience
F1 Describe your previous voluntary experience
F2 Describe the activities you undertook that demonstrated commitment to the community, spirit of service, and/or 'give back/go back' qualities:
F3 Describe your aspirations for social change and how you plan to achieve social change through your career
F4. Which sectors do you plan to impact through your social change aspirations?
Agriculture
Skilled Trades
Small Business / Entrepreneurial
Social & Humanitarian services
Health & Medical
Information Technology
Public Service / Government
Religious
Education
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Other
If ‘Other’ please explain …………………………………………………………………………. F5. Which sectors do you plan to impact through your career aspirations?
Agriculture
Skilled Trades
Small Business / Entrepreneurial
Social & Humanitarian services
Health & Medical
Information Technology
Public Service / Government
Religious
Education
Other
If ‘Other’ please explain ………………………………………………………………………….
F6 Do you have any form of disability?
Yes No
F7 If yes, what form of disability?
F8 How did you hear about the Scholars Program:
Radio Newspaper Poster MCF Staff
Former School Friend/word of mouth Other, specify …………………..
F9 What career do you plan to pursue? (I.e. Doctor, Humanitarian Relief Worker, Entrepreneur, Teacher, etc.)
I declare that all the information provided here is true and accurate to the best of my knowledge, and I have read and understood the note to applicants below.
Applicant: Parent/guardian:
Signature and Date: ______________________/_____/2016
Signature and Date: _______________/_____/2016
Name: Name:
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Please note: The decision of The MasterCard Foundation Scholars Program Selection Committee at Makerere University for award is final.
SECTION G: TO BE COMPLETED BY THE HEAD TEACHER OF YOUR FORMER ADVANCED LEVEL SECONDARY SCHOOL
Please provide your assessment (to the best of your knowledge) about the applicant on:
Academic ability
Excellent (among the top 10) Very good (top 20) Good (top 35) Fair (top 50)
Financial ability:
Rich Middle-class Economically Disadvantaged Highly economically disadvantaged
Name and Signature of Head Teacher (with date and stamp)
Name: ____________________________________ Signature ________________________ Stamp ________
Mobile No. ___________________________________Date: _________________/_________________/__________
SECTION H: TO BE COMPLETED BY LOCAL COUNCIL 1 OFFICIALS FROM THE DISTRICT OF RESIDENCE
VERIFICATION OF THE APPLICATION LC I Chairperson
a) Surname________________Other name(s) ______________________________________________________
b) Village (LCI) _________________Parish _________________Sub-County__________________ District ______________________
c) Does the applicant reside in this village? Yes/No__________________ If yes, for how long_________________
d) For how long have you known the applicant? ____________________________________________________________________
e) What is the applicants’ district of origin? ________________________________________________________________________
f) How many biological children are in her/his family? ___________________ How many are independent or working? ________________
g) What does/ did the father do to earn a living? _____________________________________________________________________________________________
h) What does/did the mother do to earn a living? ______________________________________________
_____________________________________________________________________________________________
i) Who was paying the applicants’ fees at secondary school level? ____________________________________________________________________________________________
j) Any other important information? ____________________________________________________________________________________________
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k) RECOMMENDATION : Strongly Recommended Recommended Not Recommended State the reason(s) for your recommendation_________________________________________________________ __________________________________________________________________________________________________________________________________________________
DECLARATION I, the undersigned, hereby declare that I have carefully checked and verified the particulars stated above and certify that they are true and accurate.
Name____________________________Signature_________________________ Stamp and Date _________
Please Turn Over
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Draw a sketch map to your residential home here.