Application Form For Basa Basic Education Programme 2014 (Page 2 of 5) in pdf

Application Form For Basa Basic Education Programme 2014 Page 2

Please fill in all required information or use separate paper if the space is not enough. Our intention is

to help your organization move beyond existing challenges. All details are important and are important

for the final selection of our delegates.

BASA BASIC APPLICATION FORM

Details

Name:

_____________________________________________________

Organisation (if applicable):

Postal address:

_____________________________________________________

______________________________________________________

Physical address:

______________________________________________________

Telephone and contact person: ______________________________________________________

Email and website (if available):_____________________________________________________

Is your organisation registered:

____________________________________________________________________________

If yes, what is it registered as

o N

Non Profit

Pty (Ltd)

Co operative

Other (specify)

Please answer the questions below to give us a clear picture of your organization and how you operate

and what your challenges are:

1. What does your organisation do?

____________________________________________________________________________

2. What is unique about your organisation/business?

T + 27 11 447 2295 / 2182/ 2743 F +27 11 447 2364 A 163 Jan Smuts Avenue • Parkwood • 2193 • Johannesburg P P.O. Box 962 • Parklands • 2121

• Mr. Kwanele Gumbi (Chairman) • Mr. Richard Cock • Mr. Mandla Langa • Mr. Gianni Mariano • Mr. Monna Mokoena

• Mr. Herman Bosman • Mr. Andre Le Roux • Ms. Gabriela Palacios-Flusk • Ms. Florence Thom • Ms. Michelle Constant

• Mr. Matthew van der Want • Ms. Mandie van der Spuy • Ms. Gail Walters • Mr. Carel Nolte

Chief Executive Officer: Michelle Constant

Company Registration 1997/001920/08

Application Form For Basa Basic Education Programme 2014 Page 2