Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697808892845.pdf (Mauritius)
REPUBLIC OF MAURITIUS MINISTRY OF EDUCATION, TERTIARY EDUCATION, SCIENCE AND TECHNOLOGY ******* APPLICATION FORM FOR SCHOLARSHIPS TO LEARNERS WITH DISABILITIES (6 PAGES IN ALL) Registration No :….......

The completed application form must be submitted to the Scholarships Section (SRM) of the Ministry of Education, Tertiary Education, Science and Technology, 1st Floor, MITD House, Pont Fer, Phoenix.
This application form must be accompanied by certified photocopies of the relevant documents: Application procedure and deadline 1.

Application Forms Application must be made on this prescribed form available at the Reception Desk of the Ministry of Education, Tertiary Education, Science and Technology, Ground Floor, MITD House, Pont Fer, Phoenix or downloaded from the Ministry’s website: https://education.govmu.org 2.
List of certified copies of documents to be submitted along with the completed application form (i) Birth certificate of applicant.

(ii) National Identity Card of applicant (iii) Educational Certificates (SC/GCE ‘O’ level/HSC/GCE Advanced Level).
(iv) Evidence of enrolment or offer of a seat in a fully accredited academic undergraduate full-time/Part time/Distance Learning academic programme of not less than the equivalent of one academic/full year of study at a recognised local University/Tertiary Education Institution duly registered with the Higher Education Commission (HEC) including details of enrolment fees, tuition fees and any other associated costs.
OR Evidence of enrolment or offer of a seat in a fully accredited full time /Part time/Distance Learning professional programme of not less than one full year of study at a recognised local Tertiary Education Institution duly registered with the Higher Education Commission including details of enrolment fees, tuition fees and any other associated costs.
OR Evidence of enrolment or offer of a seat for a fully accredited full-time /Part time/Distance Learning National Diploma/ Higher National Diploma course in a local training institution, duly registered with the Mauritius Qualifications Authority, including details of enrolment fees, tuition fees and any associated costs.

(v) Evidence of nature of disability from either a Government Medical Practitioner or a Private Health Institution.

(vi) Evidence of any basic invalid pension received.
(vii) Evidence of any Scholarship/Sponsorship being received/to be granted for course applied for (if applicable).

In the absence of certified photocopies applicants should bring along their originals to enable this Ministry to certify copies of documents.

Original documents will be returned to applicant after photocopies have been certified.
Application Form for Scholarships to Learners with Disabilities Page 1 of 7 IMPORTANT: Incomplete, inaccurate, inadequate filling of the form or non-submission of documents requested for may lead to disqualification.

SECTION A 1.Surname of Applicant (in block letters) Other Names (in block letters) Maiden Name (if applicable) (in block letters) 2.

Gender: Male Female 3: 3.

Marital Status: Single Married Others (specify) : ………………….

4.

Date of Birth 6.

National ID Number : 5.


Age: ………………years (by closing date of application) 7.

Country of birth: ...........................……………………………………... 8.

Nationality: Mauritian Other (please specify) .................................................

If naturalised (certificate of naturalisation to be annexed) Date of Naturalisation: ............................................ 9.

Place of Permanent Residence Mauritius Rodrigues Outer Islands 10.
Residential Address ………………………………………………………………………………………….. in Mauritius ………………………………………………………………………………………….. 11.

Residential Address : ...........................................................................…………………………………… in Rodrigues/Outer Islands (if applicable) ...........................................................................…………………………………… 12.

Telephone No : Residence ..........................................

Mobile Phone No :………………………….. Email Address: ……………………………………………………………………….

13.
13.

Present Occupation of applicant: Student/Unemployed/Employed/(Other Specify) ………………………… 14.

Name of Father: ……………………………………………..

Phone No: …………………………………… Name of Mother: …………………………………………….. ….Phone No: …………………………………… Name of Spouse (if applicable): ………………………… Phone No: …………………………………… Name of Guardian (if applicable) : ………………………… Phone No: …………………………………… Application Form for Scholarships to Learners with Disabilities Page 2 of 7 15.
Educational Records:- (i) Cambridge School Certificate/G.C.E ‘O’ Level Results Year …………………………Examination Centre No :……...................... Index No ….................……………….

School : .......................................................................................................................Aggregate: ……………… Subjects Subject Grade ……………………………………………….……… ……………………………… ……………….……………………………………… ……………….……………… ……………………………………….……………… ……….……………………… ……………………………………………………….
……………………………… ……………………………………………………… ……………………….……… ……………………………………………………… ……………………………… ……………………………………………………… ……………………………….

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(ii) Cambridge Higher School Certificate Results Year : .................................

Examination Centre No : .............................. Index No …………………………… School : .....................................................................................................................................................................
Subjects Subject Grade Advanced Level ……………………………………………….……… ……………………………… ……………….……………………………………… ……………...……….……… ……………………………………….……………… ……………………………… ……………………………………………………….

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Application Form for Scholarships to Learners with Disabilities Page 3 of 7 Advanced Subsidiary Level ……………………………………………….……… ………………………… ……………….……………………………………… ………………………… ……………………………………….……………… ………………………… ……………………………………………………….

………………………… Note 1: institution.


Candidate must include a copy of his/her letter of enrolment from his/her 16.
Details of Course enrolled for: Institution: …………………………………………………………………………………………………………….. Name of Course: ………………………………………………………………………………………………………… Duration (Years): …………………Mode (Full time/Part Time/DL/others) ……………………….. Expected Start Date: .................... Expected Completion Date: ..................... Indicative Costs (Rs)* per academic year…………………………………………… (Costs should include Tuition fees, General fees, Registration fees) Note 2: the MQA website: www.mqa.mu The list of recognised accredited courses in registered TVET institutions is available on Note 3: the Higher Education Commission website: www.tec.mu The list of fully accredited courses by the Higher Education Commission is available on 17.
Other Educational Scholarship/Sponsorship/Financial Assistance Are you benefiting from any other Scholarship/Sponsorship/Financial Assistance for the course/s for which application for scholarship is hereby being made?

(Please tick as appropriate) Yes …….

No ……If “Yes” please provide the following details as appropriate: (i) Amount of Scholarship/Sponsorship/Financial Assistance received: Rs …………… per annum.
(ii) Name of Organisation/Institution providing the Scholarship/Sponsorship/Financial Assistance ………………………………………………..………………………………………………………….. (iii) Contact person from the organisation/Institution at (ii) above: Name ……………………………………………….

Phone No ...............................

Application Form for Scholarships to Learners with Disabilities Page 4 of 7 Address ……………………………………………………………………………………… 18.
Are you a beneficiary of the Basic Invalid Pension from Ministry of Social Integration, Social Security and National Solidarity?

Yes No If yes, indicate the amount.

: ……………………………………………………..

SECTION B: Disability Information Purpose and Instructions This section is used to determine your eligibility for assistance under the Scholarships to Learners with Disabilities.
Eligibility is based on the functional impact of the disability on your ability to participate in a higher educational environment and, in some instances, the permanence of this disability.

Ensure that you complete all sections.

If you require additional space, please attach a letter with the additional information.

Provide clear statements about your disability-related functional limitations and/or restrictions.

19.
Nature of Disability – Please tick as appropriate Physical Disability ( e.g., orthopaedic, mobility problems, spinal cord injuries, spinal deformity, spina bifida, hemiplegia, cerebral palsy, sensory integration deficits , visual spatial perception etc) Social, emotional and behavioural disturbance (e.g., attention deficit hyperactive disorder, combined hyperactive – impulsive and inattentive, schizophrenia, anxiety disorders, obsessive compulsive disorder, emotional and behaviour disorders and antisocial personality disorder etc) Intellectual and Brain related disabilities (e.g., dyslexia, dysgraphia, dyspraxia, dyscalculia, gifted, down syndrome, fragile x syndrome, William syndrome, Epilepsy and epileptic syndromes etc) Visual Impairment Communication Disorder (e.g.
hearing impaired, speech disorders, language disorders etc) Autism Spectrum Disorder (e.g., autism, Asperger’s, pervasive developmental disorders etc) Multiple Disabilities (e.g., restricted movements, skeletal deformities, sensory disorders, seizure disorders, lungs and breathing control etc) Other Health related disabilities immunodeficiency virus, lyme's disease, lupus erythematosus, multiple sclerosis, renal disease or failure etc) (e.g., cancer, chemical dependency, epstein barr virus, human 20.
Please provide further details on the nature and degree of disability in the space below.

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21.


Support Requirements Application Form for Scholarships to Learners with Disabilities Page 5 of 7 Optional and for information only – Check all that apply.

I require specialized equipment in order to participate in postsecondary education.

Specify equipment Required I require specialized services or arrangements in order to participate in post-secondary education Specify services and arrangements required 22.
Contact details of Registered Medical Practitioner as reference.

…………………………………………………………………………………………………………….

…………………………………………………………………………………………………………… 23.

False Information I understand that, in case false information is submitted, any scholarship that may have been granted will be cancelled forthwith and amount disbursed should be refunded within 3 months of the date of notification.

I may also be liable for prosecution.

24.


Declaration I declare that, to the best of my knowledge and belief, the particulars given on this form are true and correct and that no information which might affect the decision of the Ministry of Education, Tertiary Education, Science and Technology has been withheld.

I hereby agree to abide by the conditions attached to the Scholarship offered by the Ministry of Education, Tertiary Education, Science and Technology.
Signature: …………………………………………………………… Name: ……………………………………………………………………………………………………………………….

Date: …………………………………………………………………….

25.

For Office use only: Application Form for Scholarships to Learners with Disabilities Page 6 of 7 Submitted on: ....................... Originals Verified by: ...................................................... Signature: ........……………………………………………..
Date: ………………………… Seal Application Accepted Application Rejected Remarks (if any…………………………………………………………………………….… ………………………………………………………………………………………………….

Signature: …………………………………………………… Date: …………………………..

Application Form for Scholarships to Learners with Disabilities Page 7 of 7