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Scholarship Application Form

Please complete this form in block letters.
Separate application forms are required if you would like to apply for more than one scholarship.

SECTION A PERSONAL DATA

1. Name
First Name Middle Name Surname

2. Permanent Address

Mailing Address (if different from permanent address)

3. Contact information
Home Phone Primary E-mail Mobile Phone Alternate E-mail

4. Gender
Female Male

5. Date of Birth (dd/mm/yyyy)

/ /

6. Identification Information
Country of Birth Country or Countries of Citizenship

If you are a national of Trinidad and Tobago, please state: Passport Number Personal Identification Number (PIN) from your Birth Certificate

Expiration Date

7. Marital Status
Single Married Common Law Legally Separated Divorced Widowed

8. Next of Kin or Emergency Contact

Name Address Home Phone Primary E-mail Mobile Phone Alternate E-mail Work Phone Relationship

9. Employment Information
Profession/Occupation Work Address (if applicable) Work Phone Work E-mail Name of Employer

Separateapplicationformsarerequiredifyouwouldliketoapplyformorethanonescholarship

SECTION B PROPOSED PROGRAMME OF STUDY

1. Level of Programme
Masters Degree Bachelors Degree

2. Duration of Programme
2 years 3 years

Have you been accepted for the next academic year? If so, please indicate your expected start date Are you awaiting acceptance? Are you enrolled in this programme? If yes, in which year? Proposed Graduation Date Month Year

Yes

No

Yes Yes

No No

SECTION C ACADEMIC AND PROFESSIONAL QUALIFICATIONS

PLEASE LIST ALL QUALIFICATIONS GAINED, GIVING INSTITUTION, EXAMINING BODY/LEVEL, SUBJECT, GRADE AND DATE AWARDED. E.G.:-| ST. MARYS COLLEGE | CXC/ORDINARY LEVEL | PHYSICS | 1 | 04/1992

1. Secondary Level
Institution Examining Body/Level Subject Grade Date Awarded (mm/yyyy)


2. Vocational Level
Date Institution From (mm/yyyy) To (mm/yyyy) Examining Body/Level Programme/Area of Study Qualifications obtained

3. Tertiary Level
Date Institution From (mm/yyyy) To (mm/yyyy) Examining Body/Level Programme/Area of Study G.P.A

4. Other Professional Qualifications

Date Institution From (mm/yyyy) To (mm/yyyy) Examining Body/Level Programme/Area of Study Qualifications obtained

SECTION D
1. Employment Record
Date Job Title/Activity From (mm/yyyy) To (mm/yyyy) Employer/Organisation Main Tasks/Responsibilities

2. Other Information
Please state briefly any other information that you feel may support your application.

SECTION E DISABILITY/SPECIAL NEEDS

1. Scholarship programmes administered by the Government of Trinidad and Tobago do not discriminate on the basis of race, religion, sex, or physical impairment. 2. Do you have a disability? Yes No If yes, please give details in the lines below.

SECTION F DECLARATION AND SIGNATURE

I hereby certify that the information that I have provided is accurate. I understand that any misrepresentation on my part may result in the rejection of my application by NALIS.

_______________________________________
Signature of Applicant

___________/______________/________
Date Month Year

Please note:
1. Copies of the following documents must accompany this application form: I. Covering letter (u.f.s. immediate supervisor) addressed to, Director, Human Resource Management Division II. Academic Certificates (original and one (1) copy of each) III. A statement describing the applicants reason for pursuing the programme IV. Curriculum Vitae V. Letters of Accreditation (applicable to the Postgraduate Programme only) VI. A professional recommendation from the immediate supervisor VII. Proof of acceptance from the University (applicable to the Postgraduate Programme only) VIII. An original and one (1) copy of Birth Certificate together with lawful affidavit where names appearing on the certificates differ in any way from those appearing on other documents and also evidence of Trinidad and Tobago Citizenship, if applicable IX. Proof of change of name, if necessary X. Copies of the bio-data pages of your unexpired passport (if available) 2. Transcripts must be issued directly from the institution attended and must be mailed under sealed cover directly to the under-mentioned address (applicable to the Postgraduate Programme only)

Attention: Director, Human Resource Management Division Third Floor, The National Library of Trinidad and Tobago Hart and Abercromby Streets, Port of Spain Republic of Trinidad and Tobago P.O. Box 547. Port of Spain Republic of Trinidad and Tobago Phone: 62-NALIS (62-62547); 623-9673; 623-6962; 623-7278; 624-1130; 624-5075; 624-4466; Fax: 627-4177 or 625-6096

E-mail: nalis@nalis.gov.tt | Website: www.nalis.gov.tt

FOROFFICIALUSEONLY
DOCUMENTSRECEIVED

BirthCertificate AcademicCertificates Passport CurriculumVitae PlanofStudy LetterofAcceptance LetterofAccreditation ___________________________________ Documentscheckedby(Signature) ____________________ Date

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