1. No category

MINING QUALIFICATIONS AUTHORITY
Please staple a
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INTERNSHIP PROGRAMME APPLICATION FOR 2015
Head & Shoulders
A.
PERSONAL DETAILS
TITLE (MR, MRS, MS, DR, etc.)
IDENTITY NUMBER
INITIALS
RACE
MALE
FEMALE
SURNAME
FIRST NAMES IN FULL
MUNICIPALITY
YEAR MATRICULATED
NAME OF COURSE (e.g: mining eng)
YEAR GRADUATED (e.g: 2013 )
NAME OF INSTITUTION (e.g Wits)
YES 
HAVE YOU EVER HAD AN MQA BURSARY OR OTHER MQA SPONSORSHIP
DATE OF BIRTH (d:m:y)
AGE AT DEC 14
POSTAL ADDRESS
PHYSICAL
NO 
ADDRESS
POSTAL CODE
POSTAL CODE
PROVINCE
DISTRICT
MUNICIPALITY/REGION (COMPULSORY, FOR REPORTING PURPOSES)
HOME TELEPHONE
AREA
NUMBER
CODE
FAX NUMBER
AREA
NUMBER
NUMBER
CODE
APPLICANT CELL NUMBER
ALTERNATIVE CELL
NUMBER
E-MAIL ADDRESS
EMERGENCY CONTACT
MQA/PRO/04/004
NAME
NUMBER
Revision: 00
Approved: COO
www.mqa.org.za
Date: 12/03/2015
PROVINCE OF BIRTH AND NAME OF HOSPITAL:
MARITAL STATUS
Single 
Married 
YES 
DO YOU SUFFER FROM ANY CHRONIC ILLNESS OR PHYSICAL HANDICAP?
NO 
If yes please give details
YES 
HAVE YOU BEEN CONVICTED OF ANY CRIME?
NO 
If yes, please give details
B.
PARENT / GUARDIAN DETAILS
TITLE (MR, MRS, MS, DR,
IDENTITY NUMBER
etc.)
INITIALS
NATURE OF
RELATIONSHIP
SURNAME
FIRST NAMES IN FULL
OCCUPATION
PLACE OF WORK
HOME TELEPHONE
AREA
NUMBER
CODE
WORK TELEPHONE
AREA
NUMBER
CODE
FAX NUMBER
AREA
NUMBER
NUMBER
NUMBER
CODE
CELL NUMBER
E-MAIL
ADDRESS
C.
REQURIED DOCUMENTATION
NOTICE
Your application for funding will be disqualified if the following certified documentation is not attached (stapled) to this application:




Copy of your ID;
Matric Certificate;
Full tertiary academic record; and
Copy of a relevant degree/diploma.
I declare that the information supplied in this application is to the best of my knowledge true and correct. I understand that any false
information will automatically disqualify me from obtaining any funding and could further lead to me being charged in a Court of Law
for fraudulently receiving funding.
SIGNATURE
PLACE
DATE
Please visit the Mining Qualifications Authority website should you wish to know more about the organization: www.mqa.org.za
MQA/PRO/04/004
Revision: 00
Approved: COO
www.mqa.org.za
Date: 12/03/2015