Section A: Personal Details

Surname:

First Name(s):

Postal Address:

Residential Address:

e-mail:

Tel:

Cell:

Fax:

Details Details of Degree/s obtained

Section B: Academic

YEAR

DEGREE

INSTITUTION

Details of academic awards, scholarships or achievements

If it has been some time since you completed your BA please provide a brief history of your employment and activities since graduation

Indicate if there is any way in which you might contribute to the diversity of the class, and explain.

Section C: Referees

Provide the names and contact information of two academic referees Name/Title Institution Telephone Email

Section D: Statement of Motivation On a separate page, please provide a brief (300-500 words) statement that outlines your reasons for choosing to pursue an Honours degree in English at UCT. You may wish to mention potential research interests.

APPLICANT SECTION
Applicant Name: Last: Home Address: Street and Number: City/Town: Home Phone #: Current School: Current Guidance Counsellors Name: State: Zip Code: First: Middle:

PARENT/GUARDIAN SECTION
Parent/Guardian Name: Last: Home Address: Street and Number: City/Town: Home Phone #: Home Email: State: Work Phone #: Work Email: Zip Code: First: Middle:

GUIDANCE COUNSELOR SECTION

Please submit the transcripts of grades, attendance, and discipline/conduct as required by the Majestic Admission Policy. In addition, submit your recommendation on the Guidance Counselor Recommendation Form. The Majestic Admission Office provides this form, as well as the Majestic Admission Policy. Name of Guidance Counselor: ______________________ I will submit the required information by the due date. Yes No If no, please explain.

SIGNATURE SECTION
The statements and information furnished by the undersigned in this application form are true and complete. The undersigned applicants parent(s)/guardian(s) give permission for representatives of the sending school to release the applicants records including, grades, attendance, conduct/discipline records, as well as any other pertinent information that may be required by Majestic for the purpose of admission. Our signatures certify that we have read and agree with the above statements. Signature of Student Signature of Parent/Guardian Signature of Current Guidance Counselor Date: Date: Date:

VOLUNTARY INFORMATION SECTION The information requested in this section is not required for admission. Submission of the information is entirely voluntary. Information submitted voluntarily by the applicant will not affect the applicants admission to the school. The information, if supplied, will be used for monitoring equal educational opportunity in the school district. In addition, note that applicants with disabilities may voluntarily self-identify for the purpose of requesting reasonable accommodations during the entire application and admission process. Applicants who are English language learners or limited English proficient may voluntarily self-identify for the purpose of receiving interpretive services during the entire application and admission process.

Gender:

Female

Male Hispanic Yes

Race: American Indian or Alaskan Native Asian or Pacific Islander Black White Combination of Two or More Races (if checked supply the code the attached list: Code:________

Person with a disability: Yes If yes, do you need accommodations during the application for admission process? If yes, please describe the accommodations needed.

Person who is an English language learner or limited English proficient: Yes If yes, do you need language assistance during the application for admission process? Yes If yes, please describe the assistance needed.

Not Hispanic or Latino One race White Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Combination of Two Races White & Black or African American White & Asian White & American Indian or Alaska Native White & Native Hawaiian or Other Pacific Islander Black or African American & Asian Black or African American & American Indian or Alaska Native Black or African American & Native Hawaiian or Other Pacific Islander Asian & American Indian or Alaska Native Asian & Native Hawaiian or Other Pacific Islander American Indian or Alaska Native & Native Hawaiian or Other Pacific Islander Combination of Three Races White & Black or African American & Asian White & Black or African American & American Indian or Alaska Native 16 17 06 07 08 09 10 11 12 13 14 15 01 02 03 04 05

Hispanic or Latino

33 34 35 36 37

38 39 40 41 42 43 44 45 46 47

48 49 50 51 52

White & Black or African American & Native Hawaiian or Other Pacific Islander 18 White & Asian & American Indian or Alaska Native White & Asian & Native Hawaiian or Other Pacific Islander 19 20

White & American Indian or Alaska Native & Native Hawaiian or Other Pacific Islander

21

53

Black or African American & Asian & Native Hawaiian or Other Pacific Islander 22 Black or African American & Asian & American Indian or Alaska Native Black or African American & Native Hawaiian or Other Pacific Islander & American Indian or Alaska Native 23 24

54 55 56

Asian & Native Hawaiian or Other Pacific Islander & American Indian or Alaska 25 Native Combination of Four Races White & Black or African American & Asian & American Indian or Alaska Native 26 White & Black or African American & American Indian or Alaska Native & Native Hawaiian or Other Pacific Islander 27

57

58 59

White & Asian & American Indian or Alaska Native & Native Hawaiian or Other 28 Pacific Islander White & Black or African American & Asian & Native Hawaiian or Other Pacific 29 Islander Black or African American & Asian & American Indian or Alaska Native & Native Hawaiian or Other Pacific Islander Combination of Five Races White & Black or African American & Asian & American Indian or Alaska Native 31 & Native Hawaiian or Other Pacific Islander 30

60

61

62

63