NEW BURSARY APPLICATION FORM IMPALA 21 October 2021 Final

BURSARY APPLICATION FORM
Please print and complete this form:
For Office Use: ATTACH YOUR

RECENT
Discipline: PASSPORT PHOTO
Please complete the application form thoroughly using BLACK INK and in BLOCK LETTERS
Send it to: Impala Rustenburg, Bursary Department, P O Box 5683, Rustenburg, 0300
or visit our website www.implats.co.za
INSTRUCTIONS:
• Make sure you read and complete every section and that the information you provide is accurate and true.
• Mark your choice with a cross in the appropriate block where applicable.
• We welcome applications from persons with disabilities. However, selection will be subject to the physical
demands of an occupation related to a degree.
PLEASE NOTE:
1. Incomplete forms will not be accepted.
2. Applications close on 30 September and no late applications will be considered.
3. If Impala has not responded within 30 days after the closing date, consider your application as unsuccessful.
Correspondence will be limited to shortlisted applicants. Should you qualify for a preliminary interview, it will
take place at our Rustenburg operations situated in the North West Province.
4. Please supply ALL information requested or give good reasons why you cannot provide it. Your application will
not be considered if you do not have university exemption, within the minimum requirements, which is:
Maths: Rating Code 5 or 60%

Science: Rating code 5 or 60%
English: Rating code 5 or 60%
5. The following should accompany this application form:

- Certified proof of your results (Gr.11 final exams and latest Gr.12 results)
- Full details of your academic transcript (Tertiary students)
- Certificate of conduct from your current university (if already studying)
- A certified copy of your personal identity document and Your curriculum vitae / resume
- Proof of residence
- Acceptance letter from a tertiary institution
1. BURSARY INFORMATION
Which discipline would you like to study?
Chemical Engineering Electrical Engineering (Heavy Current Only)
Geology (Mining / Exploration) Mining Engineering
BSC Chemistry B.Com Accounting
Extractive Metallurgy B.Com Human Resources
Mechanical Engineering Survey (Mining)
Nursing Teaching
2. BIOGRAPHICAL PARTICULARS
dd / mm / yyyyy
Title: Miss Mr. Gender: Female Male Date of Birth
Surname: ____________________________________ First Names: __________________________________________
Nickname: ____________________________________ ID Number: ___________________________________________
Home Language: ____________________________________ Nationality: RSA Other
Do you have a disability? ______________________________ If other specify: _________________________________________
Size of shoe / boot: __________________________________ Overall size: ___________________________________________
(This information is needed should you be invited for a site visit)
Postal Address: ________________________________________________________________________________ Code: ________
Physical Address: ________________________________________________________________________________ Code: ________
Contact Tel: ( ) ___________________________________ 2nd Contact Tel: ( ) ___________________________________
Cell phone: ( ) ___________________________________ Province:____________________________
ALTERNATIVE CONTACT DETAILS SHOULD APPLICANT BE UNAVAILABLE

Relationship: ______________________________________________________________________________________________
Surname: ____________________________________ Initials: ___________________________________________
Contact Tel: ( ) ____________________________________ Cell phone: ( ) ____________________________________
PARENT / GUARDIAN
Relationship: ______________________________________________________________________________________________
Surname: ____________________________________ Initials: ___________________________________________
Is your parent / guardian employed by Impala? Yes No If yes, where? ____________________ Industry No. ___________
If no, by whom? ____________________________________ Work Tel No: ( ) ____________________________________
3. EDUCATION DETAILS
Are you still attending school? YES NO Grade: ___________________________________________

Name of School: ______________________________________________________________________________________________
Contact Tel: ( ) ____________________________________ Fax Number: ( ) ____________________________________
Year of Matriculation: ________________________________ Please attach a certified copy of most recent results / matric certificate
4. UNIVERSITY STUDENTS
Year of Study (current)________________________________ Support Programme 1st 2nd 3rd 4th
Name of University: __________________________________ Course: (e.g. Bsc Mech Eng

Mi
II)______________________________
d Mi Mi
Student Number: __________________________________ Please attach a certified updated academic record from the institution
Do you have a bursary at present? YES NO If yes, from whom? ______________________________________

What is the value of the bursary?_________________________________________________________________________________
Are there any work or financial obligations attached to this bursary? YES NO
If yes, give details: ___________________________________________________________________________________________
Authorised Signature of applicant: ___________________________________ Date: ___________________________________
5. CAREER
Do you currently have a scholarship, bursary or loan? YES NO

If yes, what is the name of the award? ____________________________________________________________________________
Who has it been awarded by? ____________________________________________________________________________
What is the value of the award? ____________________________________________________________________________
Is there a service obligation attached to the scholarship, bursary or loan? YES NO
Have you been employed since leaving school? YES NO Full Time Part Time
If yes, give details and attach a record of service or testimonial.
Details of current and / or previous employment:
EMPLOYER OCCUPATION YEAR

FROM TO
DECLARATION
I herby give consent to undergo any medical tests / examinations required by IMPLATS.
1. I confirm that the information contained in this application is, to the best of my knowledge, correct and truthful and I
understand that if it is not fit, I may be eliminated from consideration in the selection process. If, after being admitted to the
training scheme, any falsehoods or omissions are discovered in my application, I understand that my Bursary Agreement may
be terminated.
2. I understand that all statements in my application may be investigated and I authorize the organization to contact the
following person who might be able to speak about my abilities and suitability for the bursary for which I have applied.
______________________________________________________________________________________________________
_________________________________________________________________________________________________
3. I understand that an investigation of me might include reference checks from my school / university / technicon / previous
employer/s. I authorize any school / university / technicon / employer to provide IMPLATS with relevant information and
opinions that may be useful in making a decision, and release such persons and organizations from legal liability in making
such statements. (Please specify persons / institutions you would like us to have contact).
______________________________________________________________________________________________________
______________________________________________________________________________________________________
__________________________________________________________________________________________________
4. I hereby indemnify IMPLATS or any IMPALA company, their Training Managers and Training Officials against any claim for
illness or accidental injury sustained by me during a visit to their operations, should I be invited to attend such a visit.
Signature of Applicant: ___________________________________ Date: ___________________________________

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BURSARY APPLICATION FORM

Please print and complete this form:

For Office Use: ATTACH YOUR

Maths: Rating Code 5 or 60%

5. The following should accompany this application form:

Chemical Engineering Electrical Engineering (Heavy Current Only)

Geology (Mining / Exploration) Mining Engineering

BSC Chemistry B.Com Accounting

Extractive Metallurgy B.Com Human Resources

Mechanical Engineering Survey (Mining)

ALTERNATIVE CONTACT DETAILS SHOULD APPLICANT BE UNAVAILABLE

Are you still attending school? YES NO Grade: ___________________________________________

Year of Study (current)________________________________ Support Programme 1st 2nd 3rd 4th

Name of University: __________________________________ Course: (e.g. Bsc Mech Eng

Do you have a bursary at present? YES NO If yes, from whom? ______________________________________

Do you currently have a scholarship, bursary or loan? YES NO

EMPLOYER OCCUPATION YEAR

Signature of Applicant: _ Date: _

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