Jamaica Values and Attitude Project
For Tertiary Students (JAMVAT)
Financial Assistance Application Form
(For Approval details visit website at www.nysjamaica.org)
_______________________________________________________________________________
Examples
Use black or blue ink and print
Each letter clearly within the box
Fill in money amounts from the
right, using numbers only
Photograph of Applicant
Select a response by placing
an ‘X’ in the appropriate box
Yes
No
Section A: Personal Particulars of Applicant
1. Last name
2. First name
1-3 Your name
3. Middle name
4. Sex
Male
5. Marital
Female
Status
Single
Separa
Widowed
Married Divorced
6. Number and street (include Apt. No.)
6-8 Your
Permanent
Address
7. Town/District (if corporate Area, use postal code &leave Parish blank)
8. Parish
9. Number and street (include Apt. No.)
9-11 Your Mailing
(if different
from nos. 6-8)
12. Your date of birth
10.Town/District(if Corporate Area, use postal code & leave Parish blank)
Day
Month
14. Home
14-15. Telephone Nos.
16. E-mail Address
17. Amount
Requested
(Estimated 30% of Tuition )
Year
13. Your Taxpayer number
15. Work
11. Parish
Do not leave blank
Section B: Applicant’s Student Status
Use abbreviation (See page iii)
18. Name of
19.Student Id
Institution
Number
20. Enrollment Status
New
21. Attendance Status
Full-time
Returning
Part-time
22. How many
years have you
been enrolled
Evening
Transfer
Code
23. Course of Study
24. Course title
Code
Mon
25. Certificate/ Diploma/Degree
Year
26. Enrollment
27b. Proposed Year
of completion
27a. Last Secondary School
Attended
____________________________________________________________________________________________________________________________
Recommended for Work Study
28. Academic
Standing
Programme
29. Recommended
for Work/Study
Programme
Not satisfactory
yes
Satisfactory
No
29.I CERTIFY THAT THE INFORMATION GIVEN IN
QUESTION 28. IS CORRECT; AND THE ACADEMIC
PERFOMANCE AND CONDUCT OF THIS STUDENT
IS ACCEPTABLE
……………………………………………………………..
SIGNATURE OF HEAD OF FACULTY, PRINCIPAL OF
INSTITUTION WHERE COURSE IS BEING PURSUED.
Section C: Employment Details of Applicant (to be completed by all applicants)
30. Status
unemployed
31. I will be retaining my
job while studying
yes
32.Iwill receive salary while
I am studying
No
yes
No
Employed or self employed
State occupation and job title- if not employed, go to question 34
33. Occupation
34. Type of
employment
Employer or Government Worker
35. State highest
exam passed
3-5 CXC/GCE
Private Employee or self Employed
Other (including unemployed)
36-38: Annual Income. 36. Amount earned from job:
38. Income from other sources
1 A’ Levels or more
Other
37. Earnings from self employment
Section D: Current Financial Assistance and Savings (to be completed by all applicants)
39. Funds held
in savings
40. Will you be receiving financial assistance such as
a scholarship, Bursary or Government aid
Yes
No
in the current academic year?
41. Assistant
to be (A)
Source of assistance
Type
Amount (no cents)
received (B)
42. Will receive
support for
Tuition fees from
Family or other
Sponsors?
yes
43. Value of expected
44. Applied or will apply for
support
Student loan this year
yes
No
no (go to section E)
____________________________________________________________________________________________________
Section E: Household Details (to be completed by ALL applicants)
45.Number of
Members
46. Number of employed
household members
47. Number of members enrolled
secondary and tertiary
Educational institutions
48. Number and street (include Apt. No.)
Household
48-50. Permanent
Address
49. Town/District (if corporate Areas, use postal code 7 leave Parish blank)
50. Parish
51. Home Telephone number
_______________________________________________________________________________________________________________
_
You must answer questions 52 - 57. Please select one item in questions 52-56 by placing an X in the appropriate box. Place an X
in the boxes for all items owned in question 57.
52. Type of dwelling [ ] separate House
the house that my
[ ] Detached
Household lives
semi-detached or
to
In is a:
[ ] Apartment or town
House or any other
55. Does your
Household own
Or rent the house
In which they
Stove
live?
[
] Owned
[
] leased or privately
rented
[
] Government
rented or other
53. The main [ ] Block and steel
material of the [ ] Wood
outer walls of
my house is:
[
54.The type of toilet [ ] Flush toilet linked
facilities used by
[ ] to NWC sewer
my household is
[ ] Flush toilet linked
] Other
56. My household’s [ ]Indoor Tap
57. My household
main source of
owns the
drinking water is
[ ]Outdoor Tap following items
(tick each item)
[ ] Other
[ ] Pit latrine or other
[
[
[
[
] Air conditioner
] computer
] Electric stove
] car
[ ] Gas
[ ] Washing Machine
[ ] Telephone [ ] T.V
Section F: List of Household Members (excluding applicants)
Household head information must be placed here or other household member if the applicant is the head
58. Last Name
59. First Name
60. M.I
58-60 Name of
Member
Code
61. Relation to
Applicant
Day
Month
Year
62. Date of Birth
.
.
63. Sex [ ] male
[ ] female
64. Occupational
status
Code
65. Is this member [ ] yes
the head of the
household?
[ ] no
66. Type of [ ] employer or
67.Last
[ ] tertiary
employment
Government
School
[ ] Private Employee
attended [ ] Secondary
[ ] or Self Employed
by this
[ ] Other
member [ ] Other
68.State the [ ] 3-5 CXC/GCE or
highest
1 -2 A levels or
exam
[ ] 3 A levels or
passed by
higher
this member [ ] Other
69. Does this
[ ] yes
member
contribute to
[ ] no
your financial
support?
_______________________________________________________________________________________________________________
_
Section F: List of Household Members (58-64 Repeat -Contd.)
58. Last Name
59. First Name
60. M.I
58-60.Name of
member
61. Relation to
applicant
Code
Day Month Year
62. Date of birth
code
63. Sex
58. Last Name
male
female
59. First Name
64. Occupational
Status
60. M.I
58-60.Name of
member
61. Relation to
applicant
Code
Day Month Year
62. Date of birth
code
63. Sex
58. Last Name
male
female
59. First Name
64. Occupational
Status
60. M.I
58-60.Name of
member
61. Relation to
applicant
Code
Day Month Year
62. Date of birth
code
63. Sex
male
female
64. Occupational
Statu
58. Last Name
59. First Name
60. M.I
58-60.Name of
member
61. Relation to
applicant
Code
Day Month Year
62. Date of birth
code
63. Sex
58 Last Name
male
female
64. Occupational
Status
59. First Name
60. M.I
58-60.Name of
member
61. Relation to
applicant
Code
Day Month Year
62. Date of birth
code
63. Sex
58. Last Name
male
female
64. Occupational
Status
59. First Name
60. M.I
58-60.Name of
member
61. Relation to
applicant
Code
Day Month Year
62. Date of birth
code
63. Sex
58. Last Name
male
female
64. Occupational
Status
59. First Name
60. M.I
58-60.Name of
member
61. Relation to
applicant
Code
Day Month Year
62. Date of birth
code
63. Sex
male
female
64. Occupational
Status
_______________________________________________________________________________________________________________
Section G: Particulars of Two Referees of referees
First Referee
70. Last name
71. First Name
70-72. Name
72. Middle Name
73. Number and street (include Apt. No.)
73-75. Permanent
Address
76. Relationship
to applicant
74.Town/District (if corporate Area, use postal code& leave parish blank)
77 Home Telephone No.
75. Parish
-
78. Occupation
79. Name of
employer or
business.
80-82. Address of
employer or
business
80. Number and street (include Apt. No)
81. Town/District (if corporate Area, use postal code &leave parish blank)
82. Parish
83. Business telephone No.
-
Second Referee
84. Last name
85. First name
86. Middle name
87-89. Address
87. Number and street (include Apt. No.)
`
`````````````````````````````````````````````
88. Town/District (if corporate Area, use postal Code & leave Parish Blank) 89. Parish
90. Relationship
to applicant
91. Home telephone No:
92 Occupation
93. Name of
employer or
business
94. Number & street (include Apt. No.)
94-96 Address
of employer or
Business
95. Town/District (if Corporate Area, use postal code &leave Parish blank)
96. Parish
97. Business Telephone Number
-
Section H Declaration
I (we) declare that the information on this form to the best of my (our)
Knowledge and belief is true, correct and complete.
In signing this document I (we) agree to:
Photograph of Applicant
1.
Participate in any evaluation study conducted by the SLB/JAMVAT
For the purpose of assessing the performance of the Financial
Assistance Programme;
2
Use the monies obtained for the intended purposes only;
3
Allow the SLB/JAMVAT to verify the information provided in this application form, using methods provided under
the law.
________________________
Signature of Applicant
___________________________
Date
_______________________
Witness
___________________________
Date
_______________________
Signature of Parent /Guardian
If applicant is under eighteen (18)
____________________________
Date
_________________________
Witness
____________________________
Date
APPLICATION FORM (JAMVAT)
STUDENT’S INFORMATION
1. Family Name:
2. First and Middle Name:
3. Date of Birth:
4. Student ID number:
4b. TRN (Required)
6. Course Dates:
Start Date:
End Date:
8. Institution attending:
5. Student’s Residential Address
7. Academic year of study (next academic year :)
9. Program/Major/Course
11. Which institution do you intend to attend next
Academic year?
10. Full Time
Part Time:
12. Program/Major/Course (next year)
13. Estimated Tuition Cost for Course: $J____________
(Next academic year only)
14. Will you able to Finance the remaining 70% of your
Tuition cost without additional Financial Aid:
15. Have you applied or do you intend to apply to the
SLB:
16. If (mistakenly) selected for both SLB and
JAMVAT, which would be your first preference:
17. How many times have you applied for JAMVAT
previously?
19. How many times did you successfully complete the
Program?
21. Are you a Jamaican citizen?
18. How many times have you been selected for
JAMVAT previously?
20. Are you the recipient of a scholarship or other
Financial Aid (other than Students’ Loan)
22. Do you have any documented disability or known
Illness:
24. Father’s occupation:
23. Mother’s occupation:
25. Telephone numbers:
E. mail address:
Fax number:
26. Extra curricular activities:
Submit on the form below, two placement options for yourself- where you could work/volunteer from 01 July – 31 December to complete
200 hours of work. (Ask your JAMVAT Liaison Aide for the Placement Area criteria). This form must be filled. Submitting this form
does not automatically guarantee approval as a JAMVAT student, nor guarantees, (having been approved), your placement there.
Workplace
APPLICANT PLACEMENT OPTIONS FORM
Workplace Address
Supervisor’s
Name
___________________________________
Student’s Signature and Date
_____________________________________
Name of Institution’s Representative
___________________________________
Signature of Institution’s Representative and Date
Supervisor’s Contact #
CODES:
SECTION B:
APPROVED TERTIARY INSTITUTIONS: QUES#18
Tertiary Institutions
Bethlehem Moravian College
Browns Town Community College
Churches Teachers College
College of Agriculture, Science and
Education
Edna Manley College of the Visual and
Performing Arts
Excelsior Community College
G.C. Foster College
Abbreviations
BMC
BTCC
CTC
CASE
Institute of Management and Production
Jamaica Theological Seminary
Knox Community College
IMP
JTS
KNOX
Jamaica Institute of Management
Jamaica Maritime Institute
JIM
JMI
Mico Teachers College
Moneague Teachers’ College
MICO
MC
Montego Bay Community College
MBCC
National Tool and Engineering Institute
Norman Manley Law School
NTEI
NMLS
Portmore Community College
Sam Sharpe Teachers’ College
School of Medical Radiation Technology
Shortwood Teachers’ College
St. Joseph’s Teachers’ College
PCC
SSTC
SMRT
SWTC
STJC
University of Technology
University of the West Indies, Bahamas
UTECH
UWI
BAHAMAS
UWI CAVE
HILL
UWI MONA
University of the West Indies, Cave Hill
University of the West Indies, Mona
University of the West Indies, St. Augustine
Northern Caribbean University
West Indies School of Public Health
Wings Jamaica
EDM
EXED
GCF
ST.
AUGUSTINE
NCU
WISPH
WINGS
Parish Codes
PARISH
Kingston
St. Andrew
St. Thomas
St. Mary
Portland
St. Ann
Trelawny
St. James
Hanover
Westmoreland
St. Elizabeth
Manchester
Clarendon
St. Catherine
CODE
Kgn
St. And
St. Thomas
St. Mary
Port
St. Ann
Trel
St. James
Hanover
West
St. Eliz
Man
Clar
St. Cath.
Course Codes and Title
The correct course and title codes are available through
the respective tertiary institutions
DEGREE/CERTIFICATION CODE LIST QUES#25
QUALIFICATIONS
CODE
Certificate or diploma for
1
completing an occupational,
technical, or educational
programme(less than two-year
programme)
Certificate or diploma for
2
completing an occupational,
technical or educational
programme(at least two-years)
Associate degree(at least two3
years)
Undergraduate degree
4
Other
5
SECTION E
h) Question 52
Separate houses detached – is a single
family house with no other house
attached. Semi-detached or part of
house is two self contained family homes
which are attached.
i) Question 55
Government
rented
is
where
Government owns or pays the rent (or
lease) for the house.
j) Question 66
Employer or Government
includes
anyone who runs a business and pays a
regular wage to an employee; and
employees of central or local government.
Private employee or self employed
includes paid employees in the private
sector
and self employed persons
who have no employees
SECTION F:
OCCUPATIONAL STATUS
Employed
Unemployed
Self- Employed
Retired
Student
Housewife
Employed/Student
RELATIONSHIP
Father
Mother
Spouse
Brother
Sister
Son/Daughter
Step Father
Step Mother
Aunt/Uncle
Grandfather
Grandmother
Father-in-law
Mother-in-law
Niece/Nephew
Cousins
Other
CODE
1
2
3
4
5
6
7
CODE
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16