Hope Fund Application Form

Details

Category: Sample Data-Articles

Published on Wednesday, 05 October 2011 15:39

Written by Kevin Llewellyn

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EMMANUEL GOSPEL ASSEMBLY

Helping Others Pursue Education (HOPE)

ACADEMIC YEAR _____/________

INSTRUCTIONS:

1. Complete Form in BLOCK CAPITALS, LEGIBLY and ACCURATELY. Forms not properly completed will not be processed.

2. Return completed Form to Emmanuel Gospel Assembly, 105e Red Hills Road, Kingston 19.

SECTION 1: PERSONAL DETAILS (Child)

1) _________________________________ ______________________________ _______________________

SURNAME FIRST NAME MIDDLE NAME

2) GENDER: M [ ] F [ ] 3) AGE ______ 4) DATE OF BIRTH ______/____/___

YYYY MM DD

5) ______________________________________________________________________________________________

PERMANENT ADDRESS: NUMBER AND STREET OR DISTRICT

________________________________ ______________________________ _____________________

CITY/TOWN OR POST OFFICE COUNTRY TELEPHONE

6) ______________________________________________________________________________________________

MAILING ADDRESS (If different from above) NUMBER AND STREET OR DISTRICT

________________________________ ______________________________ _____________________

CITY/TOWN OR POST OFFICE COUNTRY TELEPHONE

SECTION 2: PERSONAL DETAILS (Parents)

(Mother’s Information)

7) _________________________________ ______________________________ _______________________

SURNAME FIRST NAME MIDDLE NAME

8) ______________________________________________________________________________________________

PERMANENT ADDRESS: NUMBER AND STREET OR DISTRICT

________________________________ ______________________________ _____________________

CITY/TOWN OR POST OFFICE COUNTRY TELEPHONE

9) ______________________________________________________________________________________________

NAME OF PLACE WHERE YOU WORK

______________________________________________________________________________________________

NUMBER/STREET

_______________________________ ______________________________ _____________________

CITY/TOWN OR POST OFFICE COUNTRY TELEPHONE

10) __________________________________________________ ______________________________

OCCUPATION How long have you been working?

11) HOW MUCH DO YOU EARN (Gross Income)

AMOUNT $__________________________ OR $_________________________ OR $______________________

Weekly Fortnightly Monthly

12) DO YOU HAVE ANY OTHER SOURCE OF INCOME

YES [ ] NO [ ]

IF “YES” STATE THE AMOUNT AND HOW FREQUENTLY YOU RECEIVE THIS AMOUNT

AMOUNT $__________________________ OR $_________________________ OR $______________________

Weekly Fortnightly Monthly

13) IF SELF-EMPLOYED, STATE THE GROSS INCOME BELOW

AMOUNT $__________________________ OR $_________________________ OR $______________________

Weekly Fortnightly Monthly

14) WHAT IS YOUR EXPENDITURE

AMOUNT $__________________________ $_________________________ $______________________

Weekly Fortnightly Monthly

15) NUMBER OF DEPENDENTS _______________

(Father’s Information)

16) _________________________________ ______________________________ _______________________

SURNAME FIRST NAME MIDDLE NAME

17) ______________________________________________________________________________________________

PERMANENT ADDRESS: NUMBER AND STREET OR DISTRICT

________________________________ ______________________________ _____________________

CITY/TOWN OR POST OFFICE COUNTRY TELEPHONE

18) ______________________________________________________________________________________________

NAME OF PLACE WHERE YOU WORK

______________________________________________________________________________________________

NUMBER/STREET

_______________________________ ______________________________ _____________________

CITY/TOWN OR POST OFFICE COUNTRY TELEPHONE

19) __________________________________________________ ______________________________

OCCUPATION How long have you been working?

20) HOW MUCH DO YOU EARN (Gross Income)

AMOUNT $__________________________ OR $_________________________ OR $______________________

Weekly Fortnightly Monthly

21) DO YOU HAVE ANY OTHER SOURCE OF INCOME

YES [ ] NO [ ]

IF “YES” STATE THE AMOUNT AND HOW FREQUENTLY YOU RECEIVE THIS AMOUNT

AMOUNT $__________________________ OR $_________________________ OR $______________________

Weekly Fortnightly Monthly

22) IF SELF-EMPLOYED, STATE THE GROSS INCOME BELOW

AMOUNT $__________________________ OR $_________________________ OR $______________________

Weekly Fortnightly Monthly

23) WHAT IS YOUR EXPENDITURE

AMOUNT $__________________________ $_________________________ $______________________

Weekly Fortnightly Monthly

24) NUMBER OF DEPENDENTS _______________

SECTION 3: MEMBERSHIP STATUS (Child)

25) HAVE YOU PREVIOUSLY APPLIED TO THE FUND?

YES [ ] NO [ ] IF YES STATE PERIOD FROM _______________ TO __________________

26) ARE YOU A MEMBER OF THIS CHURCH?

YES [ ] NO [ ]

7) ARE YOU A MEMBER OF

[ ] SUNDAY SCHOOL [ ] YOUTH FELLOWSHIP [ ] OTHER, (Please specify) ___________________

HOW LONG? [ ] 0 – 2 years [ ] 2 – 5 years [ ] over 5 years

SECTION 4: ACADEMIC RECORD (Child)

28) NAME OF INSTITUTION (Secondary/Primary)

SECTION 5: REFERENCES (Child)

29) GIVE THE NAMES AND ADDRESSES OF TWO (2) REFEREES (preferably church or school)

(1) (2)

NAME _____________________________________ NAME_____________________________________

ADDRESS __________________________________ ADDRESS __________________________________

____________________________________________ ____________________________________________

TEL # ______________________________________ TEL # ______________________________________

RELATIONSHIP TO CHILD ___________________ RELATIONSHIP TO CHILD ___________________

SECTION 6: DECLARATION

30) I HEREBY CERTIFY THAT I HAVE READ AND UNDERSTOOD THE INSTRUCTIONS AND THE INFORMATION NECESSARY FOR COMPLETING THIS APPLICATION. I ACKNOWLEDGE THAT THE INFORMATION GIVEN IN THIS APPLICATION IS COMPLETE AND ACCURATE, AND I UNDERSTAND THAT MAKING FALSE OR FRAUDULENT STATEMENTS ON THIS APPLICATION MAY RESULT IN DENIAL OR CANCELLATION OF FUNDS BY THE EMMANUEL GOSPEL ASSEMBLY H.O.P.E. FUND.

___________________________________________________ ______________________________

Mother’s Signature Date

___________________________________________________ ______________________________

Father’s Signature Date

___________________________________________________ ______________________________

Child’s Signature Date

N.B. THIS APPLICATION MUST BE ACCOMPANIED BY THE FOLLOWING ORIGINAL DOCUMENTS:

1. MOST RECENT SCHOOL REPORT; and

1. MOST RECENT SCHOOL PAYMENT VOUCHER