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MINISTRY OF HIGHER AND TERTIARY EDUCATION, SCIENCE AND
TECHNOLOGY DEVELOPMENT STUDENT LOAN APPLICATION SELECTION
CRITERIA FORM
Please read this Form before completing it
When you have completed this application form, please submit it through your
State University/ Polytechnic/ Teachers College/ Industrial Training College
Applicant will be disqualified for providing any false information
CONDITIONS RELATING TO THE LOAN APPLICATION SELECTION CRITERIA
1. (i) Section A to be completed by the Student
(ii) Section B to be completed by the Parent/Guardian/Loan Guarantor
(iii) Section C to be completed by the Institution.
2. The student must be a citizen of Zimbabwe. The surety must be a permanent
resident or citizen of Zimbabwe.
3. Loans are meant to assist, first and foremost, needy students.
4. Payment of loans to the student shall cease if conduct, attendance or
performance is unsatisfactory. In such cases, loans advanced together with
interest accrued shall be repayable forthwith.
5. Repayment of loan shall be within one (1) year from the date money
is borrowed otherwise next application will not be considered.
SECTION A: Student Particulars
(To be completed by the Student)
1. Names (Surname): …………………………… First Name(s):…………………………..…..
Gender: ……………………………………………………………………………………………..….
2. Date of Birth …………………………………… Place of Birth …………………………………
3. Marital Status ………………………………………………………………………………………….
4. Residential Address ………………………………………………………………………………….
………………………………………………………………………………………………………………
5. Postal Address ……………………………………………………………………………………….
……………………………………………………………………………………………………………..
6. Current Physical Address: ……………………………………………….……………………..
……………………………………………………………………………………………………………..
7. Email Address: ………………………………………………………………………………………..
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8. Personal Mobile Number(s): …………………………………………………………………….
9. Are you a citizen of Zimbabwe? ……………………………………………………………….
10. National I. D. Number: …………………………………………………………………………….
11. Passport Number: ………………….……… Date of Issue: ……………….……………….
12. Last School Attended: …………………………………..............................................
Address: …………………………………………………………………………………………………
Tel: Number(s): ………………………………………………………………………………………
13. Year ……………………….. Highest Qualifications …………………………………………..
14. Next of Kin 1
Relationship to Student ……………………….. Profession ……………………………….
Residential/Physical Address …………………………………………………………………..
…………………………………………………………………………………………………………….
Full Names ……………………………………………………………………………………………
Address …………………………………………………………………………………………………
Contact Mobile Number(s) ………………………………………………………………………
Email Address (if applicable) …………………………………………………………………..
Next of Kin 2
Relationship to Student ……………………….. Profession ……………………………….
Residential/Physical Address …………………………………………………………………..
……………………………………………………………………………….……………………………
Full Names ……………………………………………………………………………………………
Address …………………………………………………………………………………………………
Contact Mobile Number(s) ………………………………………………………………………
Email Address (if applicable) …………………………………………………………………..
15. If the next of kin lives in the Rural Areas, please supply the following
information:
Name of Village ……………………………………………………………………………………..
Name of Village Head ……………………………………………………………………………..
Name of Chief ………………………………………………………………………………………..
Province …………………………………………………………………………………………………
Nearest Police Station ……………………………………………………………………………..
Nearest School ……………………………………………………………………………………….
16.
YEAR SUBJECT GRADE OF PASS EXAMINING
BODY
“O” LEVEL SCHOOL “A” LEVEL SCHOOL
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17. Details of the Guarantor
Full Names ………………………………………………………………………………………………
Residential Address ………………………………………………………………………………...
Postal Address …………………………………………………………………………………………
Mobile Number(s) ……………………………………………………………………………………
Email Address …………………………………………………………………………………………
Name of Village ………………………………………………………………………………………
Name of Village Head ……………………………………………………………………………..
Name of Chief ………………………………………………………………………………………..
Nearest Police Station …………………………………………………………………………….
Nearest School ………………………………………………………………………………………
District ………………………………………………………………………………………………….
Province …………………………………………………………………………………………………
If you were supported by BEAM or any other charitable organisation,
please attach proof from the last school, signed and date stamped
by the Ministry of Primary and Secondary Education administrative
systems.
18. PARTICULARS OF PROPOSED COURSE (attach offer letter and/or
fees invoice and last result slip)
Name of Institution ………………………………………………………………………………….
Programme (Certificate, Diploma, Degree) …………………………………………………
………………………………………………………………………………………………………………
Faculty/Department ………………………………………………………………………………..
Duration of Course in Years ……………………………………………………………………..
Semester/Term you will be entering ………………………………………………………...
Date Course Commences …………………………………………………………………………
Year of Completion ………………………………………………………………………………….
Please note that all approved loans shall be paid directly to the
accounts of Institutions, balance to be paid to the student’s account
STUDENT BANKING DETAILS
Name of Account: ………………………..………………………………..………………………
Name of Bank: ………………………………………………………………..…………………….
Account Number: ……………………………………………………………………………………
Branch: …………………………………………………………………………………………………
19. DECLARATION BY STUDENT
I, ………………………………………………………………. am applying for a Loan of
Z$..................................................... to further my studies. I am unable to
pay for my fees on my own because of the following reasons:
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
(Provide or attach proof/evidence where necessary)
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I declare that the information I have provided is, to the best of my knowledge
and belief, correct. I further declare that any false information that I supplied
automatically nullifies this application.
Date: …………… Signature of Student: ……………………… Mobile No: ……………
Full Names of Witness 1:
………………………………………………………………………..
I.D. Number: ………………………………………………………………..………………………
Date: …………… Signature of Witness: …………………… Mobile No: …………….…
Full Names of Witness 2: ……………………………………………………………………..
I.D. Number: ……………………………………………………..…………..………………………
Date: ………….. Signature of Witness: ………………….. Mobile No: …………………
SECTION B: PARTICULARS OF PARENT/GUARDIAN
(To be completed by parent/guardian/spouse)
PARENT /GUARDIAN/SPOUSE (if married)
1. Full Names (Surname First) ………………………………………………………………………
2. Relationship to student …………………………………………………………………………….
3. Residential Address …………………………………………………………………………………
…………………………………………………………………………………
…………………………………………………………………………………
5. Postal Address …………………………………………………………………………………
………………………………………………………………………………..
Current Physical Address …………………………………………………………………………
……………………………………………………………………………………………………………..
If parent/guardian/spouse lives in the Rural Areas:
Name of Village ……………………………………………………………………………………..
Name of Village Head …………………………………………………………………………….
Name of Chief ……………………………………………………………………………………….
District ………………………………………………………………………………………………….
Province ……………………………………………………………………………………….……….
Nearest Police Station ……………………………………………………………………….……
Nearest School ……………………………………………………………………………….………
6. National I.D. Number: …..………………… Phone Number(s): …………………………
7. Occupation (a) Formal Employment
Name and Address of Employer ……………………………………………………………….
………………………………………………………………………………..
………………………………………………………………………………..
Salary per month ………………………………… (Attach latest pay slip)
(b) Self-Employment
State nature of self-employment and the location where you usually
carry out this business ………………………………………………………………….
……………………………………………………………………………………………………
……………………………………………………………………………………………………
Other sources of income ……………………………………………………………….
…………………………………………………………………………………………………..
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8. Bank details of surety:
Account Name: ……..……………………………………………………………………………..
Account Number: ……….…………………………………………………………………………
Bank Name: …………………………………………………………………………………………
Branch: ………….…………………………………………………………………………………….
OR
Eco Cash/Tele Cash/One Money Number: ………….….…………………………………
9. Mobile Number(s): …………………………………………………………………………………
10. Are you a citizen of Zimbabwe? ………….……………………………………………………
11. Are you resident in Zimbabwe? If not, state country of residence
…………………………………………………………………………………………………..………..
12. State any movable/immovable property (e.g. house, cattle, vehicle etc)
…………………………………………………………………………………………………………….
…………………………………………………………………………………………………………….
I, ……………………………………………………..………………………….. declare that the above
information is, to the best of my knowledge and belief, true and correct.
Date: ………………………………. Signature: ……………………………..……………………………
SECTION C: COMMENTS BY THE INSTITUTION LOAN SELECTION
COMMITTEE
1. Is the information from the student the same with that provided by the
parent/guardian/loan guarantor? ………………………………………………………..
………………………………………………………………………………………………………………
2. Recommended/Not Recommended (Justify) ………………………………………………
……………………………………………………………………………………………………………..
……………………………………………………………………………………………………………..
……………………………………………………………………………………………………………..
……………………………………………………………………………………………………………..
……………………………………………………………………………………………………………..
……………………………………………………………………………………………………………..
……………………………………………………………………………………………………………..
……………………………………………………………………………………………………………..
……………………………………………………………… …………………… ……………
Member of the Selection Committee Signature Date
……………………………………………………………… …………………… ……………
Chairperson of the Selection Committee Signature Date
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3. BANK DETAILS OF THE INSTITUTION:
Account Name: ……….……………………………………………………………………………..
Account Number: ……………………………………………………………………………………
Bank Name: ………..…………………………………………………………………………………
Branch: ……….………………………………………………………………………………………..
OFFICIAL DATE STAMP
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