ALL QUESTIONS MUST BE COMPLETED Application Form ALL REQUESTED DOCUMENTS MUST BE ATTACHED

SECTION 1—Applicant’s Personal Data

1.1 Name: _________________________________________________________________________________________________
Surname First Middle Title
1.2 Date of Birth (dd/mm/yy): _______ / _______ / _______ 1.3 Gender: Female Male
1.4 Country of Birth: ____________________________ Attach copy of Birth Certificate.
1.5 Trinidad and Tobago Passport Number: ____________________________
Trinidad and Tobago National ID Number: _________________________Attach copy of Passport or National ID Card.
1.6 Address: ____________________________________________________________________________________
Town: ____________________________City:_____________________Country:__________________________
Attach Utility Bill for verification of address.
1.6a Mailing Address (if different from home address in 1.6 above):_________________________________________
_______________________________________________________________________________________________________
1.7 Telephone Contacts: Home: _____________ Cell: ______________ Work: ____________________
1.8 Email address: _____________________________________
1.9 Marital Status: Single Married Common Law Separated Divorced Widowed
1.10 Employment Status: Full-Time Part-Time Other (Seasonal, Casual) Not Employed
1.11 Dependant: Yes No
1.12 Applicant (and spouse, where applicable)
reside together separate residence with parents with relatives
1.13 If spouse is also a student, year of expected graduation ____________

SECTION 2—Institution and Programme Data

2.1 Institution: Local Regional (Mona, Cave Hill, Bahamas etc) Other approved with special arrangements
2.2 Institution Name: _____________________________________________________________________________
2.3 Institution Address: ___________________________________________________________________________
Town:____________________________City:_____________________Country: __________________________
2.4 Institution Telephone No. ___________________________________
2.5 Student Registration No. ____________________________________
2.6 If Caricom Institution or Distance Learning programme, please provide Registrar’s/Foreign Student Advisor’s name:
____________________________________________________________________________________
2.7 Programme Name: ____________________________________________________________________
2.8 Programme Level:
Certificate Diploma Advanced Diploma Associate Degree
Bachelor’s Degree: BA BSc BEd BTech LLB
BEng DDS DVM MBBS Other _______
Professional Qualification
Postgraduate Diploma
Master’s Degree
Doctoral Degree
2.9 Are you registering/registered as a Full Time or Part Time student?
Full Time Part Time
2.10 Duration of Programme (calendar years):
1 year or less 2 years 3 years 4 years 5 years 6 years
2.11 Programme Year for which you are seeking assistance:
Year 1 Year II Year III Year IV Year V Year VI
2.12 Academic year of the programme for which you are seeking assistance:
______________________________ to _______________________________
2.13 Address for residence during course of study (if different to address in 1.6 above):
_____________________________________________________________________________________
Town:____________________________City:_____________________Country: __________________________
2.14 New Student Continuing Student
Continuing students: Attach Result Slip(s) for previous year and copy of completed Continuing Registration Form.
New Students: Attach copy of Acceptance Letter and copy of completed Registration Form (stamped by TLI).
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 SECTION 3—Tertiary Expenses
3.1 Fill in Table 3.1 below.
Total Cost:
All expenses related to the programme must be listed below in the Total Cost column to enable an assessment of the overall cost
of studying for the period indicated in question 2.12.
Amount Already Covered:
Indicate the amount for which you have already determined/sourced coverage in the Amount Already Covered column.
Source of Coverage:
Indicate using the appropriate letter from the following list in the Source of Coverage column in table 3.1 below:-
A Bank Loan
B USGLF or SRLF
C Parents/Guardian
D Personal Funds from savings or salary
E Awards, Scholarships, Grants
F Other (please state) _________________________________________________
G GATE Table 3.1
Item Total Cost Amount Source Of Help For Official Use
TT$ Already Coverage Assistance Sought Amount
Covered TT$ A–G TT$ Approved TT$
Annual Tuition
Books
Accommodation
Airfare
Other Materials
Administrative
Expenses
Living Expenses
Other
Totals

Each entry must be accompanied with supporting documentation that is to be firmly attached to this application.

Where foreign currencies apply, indicate the foreign currency amount and the exchange rate used to determine the TT$ amount
entered in the table in the space under the item.

SECTION 4—Household Expenses

4.1 Number of persons in household: ________
4.1.1 Household Income Contributors (residing in the same location as applicant)
Table 4.1.1
Name Age Occupation Relationship to Applicant

4.1.2 Other Household Members

List in Table 4.1.2 below any members of the applicant’s household who are not employed, such as minors or disabled
household members. Table 4.1.2
Name Age Status Relationship to Applicant

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4.1.3 Household Members excluding applicant pursuing tertiary education
List in Table 4.1.3 below any relevant member from Table 4.1.1 and/or 4.1.2. Table 4.1.3
Name Institution Programme Receiving Scholarship/
Bursary/Grant? Y/N

4.2 Household Income

This includes salary, scholarship or award funds, benefit payments e.g. disability, welfare etc., child support, alimony, rental
income, other investment income etc. List these in Table 4.2 below.
Table 4.2
Name/Source Type of Income Annual Gross Annual Net of PAYE, For Official Use
NIS and HSc

Total:
Each entry must be accompanied by supporting documentation in the form of a pay slip, TD4, cheque stub, receipt,
bank statement etc.

4.3 Household Expenditure

This includes utility payments, loans, living expenses, pension plan deductions, health plan deductions, school fees, land
& building taxes, medical supplies etc. List these in Table 4.3 below. Table 4.3
Item Average Monthly Cost Annual Cost For Official Use

Total:
4.4 Household Assets
These include property, motor vehicles, furniture, saving accounts, stocks, life insurance policies etc.
List these in Table 4.4 below. Table 4.4
Item Approximate Current Value For Official Use

Total:
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4.5 Household Liabilities
These include mortgage loans, other loans etc. List these in Table 4.5 below. Table 4.5
Item Approximate Balance Owing For Official Use

Total:

4.6 Do you/did you have any contractual obligations with respect to Scholarships/Bursaries/Loans?
__________________________________________________________________________________________________
4.7 If yes, describe the contractual obligations?
__________________________________________________________________________________________________
4.8 What arrangements have you made/will you make to fulfil existing contractual obligations?
__________________________________________________________________________________________________
4.9 References:
Name two responsible persons by whom confidential references about you can be obtained.
4.9 (i) Name:___________________________________________________________________________________________
Occupation: __________________________________________________________________________
Address:_________________________________________________________________________________________
Telephone Contacts: Home: _____________ Cell: ______________Work: _________________
4.9 (ii) Name: __________________________________________________________________________________________
Occupation: ___________________________________________________________________________
Address:_________________________________________________________________________________________
Telephone Contacts: Home: _____________ Cell: ______________ Work: _________________
4.10 Are you willing to personally guarantee repayment of the approved loan in accordance with the repayment provision of
HELP? Yes No
4.11 Reference (a parent, legal guardian or sponsor):
Name: ________________________________________________ Age: _______
Address: ____________________________________________________________________________________
Town:____________________________City:_____________________Country: __________________________
Telephone Contacts: Home: _____________ Cell: ______________Work: __________________
Occupation:___________________________________________________________________________
Relationship to Applicant: ____________________________________________

SECTION 5—Declaration
• I declare that the information provided on this application is true and correct
• I am aware that this application will be subject to a thorough review and may be selected for a detailed audit by the Funding and
Grants Administration Unit of the Ministry of Science, Technology and Tertiary Education
• If selected for a detailed audit, I am committed to cooperating fully with the officers assigned to perform the audit
• I am aware that on application my credit or other information provided may be used, given to, obtained, verified, shared and
exchanged with others, including credit bureaus, mortgage insurers, registries, other approved companies and other persons
with whom I have financial dealings as well as any other person, as may be permitted or required by law. I authorize any person
contacted in this regard to provide such information
• I am aware that a false declaration can be subject to a fine or summary conviction.

Student’s Signature: ___________________________ Date (dd/mm/yy): _____/_____/______

(If the student is under 18 years this agreement must be signed by the Parent, Guardian or other responsible person over age
18. In signing below the Parent, Guardian or other responsible person approves all the Student’s obligations stated herein and
constitutes a guarantee of the Student’s obligations.

Parent Guardian Signature:___________________________ Date (dd/mm/yy): _____/_____/______

GUARANTEE
The Ministry of Science, Technology and Tertiary Education is committed to treating the above information with strict confidence.
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