2019
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Mastercard Foundation Scholars Program at KNUST/ASU
3+1+1 International Accelerated Degree Program (IADP) Scholarship
Application Form
(2019/2020 ACADEMIC YEAR)
2019
Instructions:
1. Attach a copy of your updated academic transcript to this application form.
2. Provide a minimum of three (3) reference letters signed and sealed independently by a person of
higher reputation.
3. Provide evidence of the income of parents/guardian. Eg. Copies of the payslips of your
parents/guardian. (if applicable)
4. Attach any other relevant documents that you believe will support your application including
copies of your birth certificate, BECE certificate, WASSCE certificate and passport biodata
page. (Please note that you would be required to present original copies of all your
certificates if shortlisted for interview)
5. Completed application forms should be delivered in person to the Mastercard Secretariat at the
2019
Office of the Dean of Students, KNUST
MCFSP, KNUST & ASU 1
IADP, 3+1+1 APPLICATION FORM
2019
SECTION A
Student’s Personal Information
Surname: ____________________________________
First Name: _______________________ Middle/Other names: ________________________________
Gender: M F Date of Birth (DD/MM/ YYYY): ________________ Age: ________
Nationality: ___________________________ Country of birth: _________________________
Native Language: _______________________
Marital Status: Single Married Separated
Do you have children Yes No If yes how many children do you have: _______
2019
Telephone number 1. _____________________ 2. ________________________
(Please make sure at least one of the numbers provided above can be reached in case of emergency)
Postal Address: _______________________________________________________________
Current Residence: _____________________________ E-mail Address: ________________________
Permanent Residence: _________________________________
Do you have a skype ID? Yes No
If yes, provide the skype ID: _________________________________
Do you have a passport? Yes No
Please provide the following details of your passport:
2019
Name: _________________________________ Date of Issue: ________________________
Passport No. ____________________________ Country of Issue: ________________________
Date of Expiry ____________________________
Have you travelled with this passport before? Yes No
If yes, on what occasion did you use it and where did you travel to.
Address where you reside (when not at school):____________________________________________
Do you have any form of disability? Yes No
If yes, specify which form of disability? Medical Physical
How long have you been living with this disability? ________________________________________
(This information will not be used against you in the selection process)
MCFSP, KNUST & ASU 2
IADP, 3+1+1 APPLICATION FORM
2019
SECTION B
Educational Background
Please list institutions you have attended in the following order;
DATE DATE CERTIFICATE
NO. NAME OF INSTITUTION
COMMENCED COMPLETED OBTAINED
1 Basic School:
2 Junior High School:
2019
3 Senior High School:
4 Tertiary:
Current Program being offered at KNUST:
___________________________________________________
2019
SECTION C
Parent Information
Please provide the following information on your parents.
Mother Father
Full Name______________________________ Full Name_______________________________
Check the box if deceased Check the box if deceased
Country of Residence__________ Age_______ Country of Residence____________ Age______
Employer Name_________________________ Employer Name__________________________
Job Title_______________________________ Job Title________________________________
Highest level of Education_________________ Highest level of Education__________________
Marital Status: Single Married Separated/Divorced
Number of children (including you):______
MCFSP, KNUST & ASU 3
IADP, 3+1+1 APPLICATION FORM
2019
SECTION D
Family Information
NB:
“Family” under this section refers to ‘a group of two or more people (one of whom is the householder)
related by birth, marriage, or adoption and residing together; all such people (including related subfamily
members) are considered as members of one family’.
“Householder” refers to the head of the household.
1. How many people, including yourself, depend on the income of your parents/householder for daily
living? ______ (Please put your answer in brackets if the head of your household is not your parent)
2. How many people including yourself, depend on the income of your parents/householder for their
2019
educational cost? ______ (Please put your answer in brackets if the head of your household is not your
parent)
3. a. Complete the table below for all members of your family/household living in your householder’s
home (including yourself) and indicate their status:
No. Full Name Age Relation to you Status (Student /
Working / Unemployed)
1
2
3
4
5
6
7
8
2019
9
10
c. For members who are in school, please provide details on the levels of their education and the
associated cost per annum;
No. Full Name Name of School Level/Stage Annual Amount
Tuition Family Pays
1
2
3
4
5
6
7
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IADP, 3+1+1 APPLICATION FORM
Complete the table below for other members of your family/household living in your householder’s
2019
home: (If member is employed give details as to the nature of employment)
No Full Name Employment Details Level of Education
.
1
2
3
4
5
6
7
8
2019
4. Have you or any of your siblings ever missed a significant part of a school term due to lack of finances?
Yes No
If yes, please explain and attach evidence:
________________________________________________________________________________
________________________________________________________________________________
_______________________________________________________________________________
________________________________________________________________________________
5. Family/Householder’s Financial Details:
a. Please provide details for your family’s monthly income from all sources:
2019
GH₵___________ from mother GH₵____________ from father
GH₵___________ from other relative GH₵____________ from other sources
TOTAL MONTHLY INCOME___________________
b. List other sources of your family’s income coming from other relatives
No. Name Relation to you Amount Frequency (How often)
1
2
3
4
6. Do you expect any significant change in your parent’s income in the coming year? If yes, please explain
why:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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IADP, 3+1+1 APPLICATION FORM
7. Tell us to the best of your ability, how much your family/household spends per month to meet its
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living expenses. Specific categories are provided below.
GH₵___________ for rent or mortgage GH₵___________ for food
GH₵___________ phone bills GH₵___________ for public transportation
GH₵___________ for medical bills GH₵___________ for electricity bills
GH₵___________ other expenses (specify)
TOTAL MONTHLY EXPENSE___________________
SECTION E
Educational Expenses
1. How much does your family spend on the education of the members of your family?
Name Level/Stage Amount spent per year
No. School Fees Books & Other educational
2019
Materials
1
2
3
4
5
2. Are your fees paid by a relative other than your parents? Yes No
Do you live with this relative? Yes No
How many other children’s fees are paid for by this same person? __________________
SECTION F
Sponsor Information
2019
1. Please provide the following information on each sponsor of your education (other than your parents).
Full Name________________________________ Full Name________________________________
Relationship to the applicant_________________ Relationship to the applicant__________________
Country of Residence____________ Age_______ Country of Residence____________ Age_______
Employer Name___________________________ Employer Name___________________________
Job Title_________________________________ Job Title_________________________________
How regular was this sponsorship: How regular was this sponsorship:
Monthly Monthly
Termly Termly
Annually Annually
2. Are you on any bursary/scholarship? Yes No
Bursary/Scholarship is provided by ______________________
If so, how much does the bursary/scholarship cover? ______________________
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IADP, 3+1+1 APPLICATION FORM
SECTION G (Not for selection purposes but counselling)
2019
Household Information
1. Who is the primary head of your household (outside of normal school session)?
____________________________________________________________________________
2. What is the gender of the primary head of your household? M F
3. What is the primary head of household’s highest level of education completed:
____________________________________________________________________________
4. What is the primary head of household’s occupation and status of employment:
____________________________________________________________________________
____________________________________________________________________________
5. a. Please tick the type of accommodation that you and your family occupy;
Parent’s House
Family House
2019
Rented premises paid for by my parent’s employer
Rented premises paid for by parent
Other (Specify)
b. Number of bedrooms in your dwelling place; ________________
c. Describe the dwelling in which you live including the roofing material, type of building
material used, number and type of rooms, location (where in the city, in rural village, etc.),
plumbing (what type of toilet, if any), electricity, and types of appliances and amenities.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
d. Type of Construction Material:
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Mud/Wattle
Mud/Brick
Cinderblock/Fired brick
Wood
Other (Please specify)
e. Roofing material of dwelling:
Metal
Cement
Thatch
Flush or pour flush toilet
f. Type of toilet facility:
VIP latrine
Uncovered pit latrine
Composite toilet
No facility/bush/field
Ecosan
Other (Please specify)
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IADP, 3+1+1 APPLICATION FORM
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g. Do you share the toilet facility with other households? Yes No
What type of flooring material do you have in your house: Mud
Wood
Tile
Cement
1. Do you have running water in your house? Yes No
2. Do you know how to use/operate the following? Tick all that may apply.
a. Mobile Phone Yes No B. Computer Yes No
C. Internet Yes No D. A Car? Yes No
2019
3. Does your family have the following at your residence?
a) Refrigerator: Yes No g) Internet Access: Yes No
b) Television: Yes No h) Electricity Access: Yes No
c) Satellite Dish: Yes No i) Phone Yes No
d) Electric Iron: Yes No j) Motorcycle Yes No
e) Desktop Computer: Yes No k) Bicycle Yes No
f) Laptop Computer: Yes No
4. Does your family own a car? Yes No
If yes, list the year, make (e.g., Honda, Toyota) and model (E.g., Civic, Prado, Corolla) of each car.
________________________________________________________________________________
________________________________________________________________________________
2019
________________________________________________________________________________
Is it a private car or Commercial Vehicle
SECTION H
Leadership & Service
a) What is your current KNUST class ranking; First Class
Second Class Upper Division
Second Class Lower Division
Pass
b) Have you received any awards or honours? Yes No
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IADP, 3+1+1 APPLICATION FORM
If yes, provide a list of all awards and honours you have received;
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________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
c) Provide a list of current and past leadership positions, extracurricular activities or
experiences:
Title/Activity/Experience Dates Primary Responsibilities
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IADP, 3+1+1 APPLICATION FORM
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d) Provide a list of current and past community service and volunteer experience:
Community Service/Volunteer Experience Date Length of Service
2019
e) Describe an experience when your academic talents and creativity helped someone in your
community.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
2019
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
f) What career do you plan to pursue?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
g) Which sector do you plan to impact through your social aspirations?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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IADP, 3+1+1 APPLICATION FORM
h) Describe your vision for your country;
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__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
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__________________________________________________________________________
DECLARATION
I hereby declare that the information herein given is a true and accurate account of my status. The
Foundation reserves the right to revoke my status as a Scholar of the Program at any time and take
the necessary legal action and sanctions against me if the information given is found to be
inaccurate.
……………………….. …………………
Signature of Applicant Date
2019
Below should be endorsed by someone with a high reputation:
I know the applicant for (how long?) ___________ and can vouch that all the information given by
him/her is credible.
Name: __________________________________________________
Status: __________________________________________________
....................................................... …………………
Signature (Stamp) Date
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IADP, 3+1+1 APPLICATION FORM
SECTION I
2019
(I)
(TO BE COMPLETED BY PARENT/LEGAL GUARDIAN – person so far responsible for
financing the education of the applicant)
1. Please provide the following information;
Surname____________________________________
First Name_______________________ Other names________________________________
Marital Status: Single Married Separated
Telephone number _____________________ Email address: ____________________
Postal Address_______________________________________________________________
Residential Address_____________________________
2019
Employment status: Employed Self Employed Retired Unemployed
Occupation Name and address of employer:
Annual Total Gross Income (GH¢): __________________________
(Salary and income from other sources. Please substantiate with a recent official salary slip, pension
slip or audited financial statement. If unemployed, please attach a sworn affidavit and declare how
you survive and your sources of funds for survival).
2019
(Please note that this information is necessary and if not provided your application cannot be
processed)
Other sources of income:
Tick where applicable and provide amount
Pension: ___________________________________________________
Investment interest: __________________________________________
Income from rent: ___________________________________________
Contributions from other sources: _______________________________
Earnings from taxi, passenger cars, corn mill, farming activities, petty trading and
remittances from family members etc.: _____________________________________
2. What is your relationship to the applicant?
Father Mother Uncle Aunt Brother Sister
Other (Specify):___________________________________________________
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IADP, 3+1+1 APPLICATION FORM
3. What is your highest level of Education? (Indicate by ticking)
2019
Tertiary Primary
Senior High School (Secondary) Middle School
Junior High School (JSS) No Formal Education
4. Please tick the type of accommodation that you and your family occupy.
Own House
Family House
Rented premises paid for by the employer
Rented premises paid for by self
Other (Specify)
5. Provide information on your dependants.
Name Relationship Age Educational level
2019
6. Indicate total amount paid in fees and other related expenses per year for dependants at each level
of education and provide proof of current attendance (Attach school bills and receipts):
Level of Education
Number of Dependants in
school at this level
Total amount paid in the
last year (GH¢)
2019
( II )
(TO BE COMPLETED BY SECOND PARENT/LEGAL GUARDIAN)
Surname____________________________________
First Name_______________________ Other names________________________________
Marital Status: Single Married Separated
Telephone number _____________________
Postal Address_______________________________________________________________
Residential Address_____________________________
Employment status: Employed Self Employed Retired Unemployed
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IADP, 3+1+1 APPLICATION FORM
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DECLARATION TO BE SIGNED BY PARENTS OR GUARDIANS
It is important that your dependant’s eligibility for the scholarship be based upon accurate
information.
I do hereby declare that all the information given above is true.
Signature or thump print of parent/legal guardian Date
Signature or thump print of second parent/legal guardian Date _______
2019
2019
FOR OFFICE USE ONLY
Receipt of Application
Name of Officer ___________________________________________________
Signature, Official Receipt stamp with date ( )
MCFSP, KNUST & ASU 14
