2015 Student Application Form

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2015
_____________________________________________________________________________________
Student Application Form
_____________________________________________________________________________________
Under - Graduate
Post - Graduate
The Registrar Academic
Tel: 012 521 4111/4979/3357
Fax: 012 521 5732
PO Box 197, Medunsa, 0204
1
STUDENT APPLICATION FORM
R 200 (TWO HUNDRED RAND) NON REFUNDABLE APPLICATION FEE MUST BE PAID AND THE
DEPOSIT SLIP ATTACHED TO THE APPLICATION FORM UPON SUBMISSION
BANKING DETAILS
Bank :
Standard Bank
Account Holder :
Branch :
Thibault Square
Branch Number :
Sefako Makgatho
Health Sciences
University
020909
Account Number : 070754128
Student Number
For Office Use
A.
ACADEMIC DETAILS
1.
2.
Academic Year
2015
1st
Choice
2nd
Choice
3rd
Choice
Mode of
Study
Qualifications you intend to follow (eg, MBChB, BSc)
Degree / Diploma
Study Level
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For office use
For office use
Full
Time
B.
For office
use
Part
Time
For office
use
Block
Release
For office
use
PERSONAL DETAILS OF APPLICANT
3.
Title
4.
Initials
5.
6.
Maiden
Name
8.
Identity
Number (RSA)
9.
10.
Passport
Number
(International
Students)
11. Passport
Expiry
Date
7.
Surname
Full
Names
Date of
Birth
2
STUDENT APPLICATION FORM
B.
PERSONAL DETAILS OF APPLICANT (cont.)
12.
Marital Status
13.
Gender
14.
Home Language /
Mother Tongue
15.
16.
Occupation
17.
Religion /
Church
Affiliation
Physical
Impairment
(eg. blind)
18.
Residential or
Physical Address
(not school address)
Code
19.
Postal
Address
Code
20.
Telephone No.
Fax No.
Cell No.
Email
C.
DETAILS / HEMIS (These Stats are Compulsory)
21.
Citizenship /
Nationality
22.
Ethnic
Group / Race
23.
Province /
State
24.
Rural /
Urban / PeriUrban
3
STUDENT APPLICATION FORM
D.
MATRICULATION DETAILS
25.
Examination
Date
27.
Examination
No.
Senior Certificate
Type
School Name
28.
29.
30.
31.
32.
26. Highest Grade
(standard if
Applicable)
Examination Department
(eg: Gauteng, etc)
Last
December
June
Examination Grade 11
Grade 12
Subjects and
Subject
results of
last
examination
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For office use
December
Grade 12
Code
For office use
Symbol
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For office use
4
STUDENT APPLICATION FORM
E.
33.
POST SCHOOL ACADEMIC ACTIVITIES
Were you previously registered at this or another
institution of higher learning? If yes, please supply
YES
the following information :
Institution
Student
Period
Was the qualification
Number
From - To
completed?
Yes
No
Yes
34.
35.
YES
36.
NO
For office use
Qualification excluded from
F.
If YES,
When (year)?
No
If you have not been at institutions of higher
learning after matriculating, what activities have
you been engaged in?
Have you previously been excluded from any
institution of higher learning? If yes, supply the
following information
Name of Institution
Date and period of exclusion Date
Grounds for exclusion (academic, financial
or disciplinary)
NO
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Period
For office use
For office use
RESIDENTIAL APPLICATION (OPTIONAL)
Would you like accommodation on campus
YES
NO
YES
NO
Student housing with catering
Please Note that accommodation on campus is not guaranteed
5
STUDENT APPLICATION FORM
G.
37.
FINANCIAL AID (OPTIONAL)
Do you require and qualify for financial assistance
YES
H.
NO
PARTICULARS OF PARENTS/GUARDIAN/ SPOUSE/ NEXT OF KIN
38.
Title
Initials
39.
Residential Address
(not postal address)
Surname
Relationship
Code
40.
Postal address
Code
41.
42.
43.
44.
Please specify which address you want
Financial statements to be sent to
Contact
Work
Home
Numbers
Is your parent/guardian or spouse a staff member
of Sefako Makgatho Health Sciences
University?
If yes, indicate his/her staff number
Are you a staff member of
Sefako Makgatho Health
YES
NO
Sciences University?
Cellphone
YES
NO
Staff
No.
6
STUDENT APPLICATION FORM
I.
DECLARATION
I, _____________________________________________________________ (full names)
hereby declare that :



All the information provided in this document is true and that I will abide with
all the rules and regulations of Sefako Makgatho Health Sciences University;
I have concluded this agreement with the knowledge and consent of my
parents/guardian/spouse or next of kin;
I undertake to notify the Registrar in writing, if I wish to cancel my registration
during the current academic semester/year and I acknowledge that I am liable
for fees payable for the respective semester/year.
Signed at___________________________________ on the ____________ day of _________
Signature of Applicant : _____________________________________________
Date : _______________________
Signature of Parents/Guardian/Spouse : _______________________________
Date : _______________________
7
STUDENT APPLICATION FORM
FOR OFFICE USE
Documents to accompany the Application Form
(attach only those that are applicable to you)
Matric Certificate
Degree Certificate
Diploma Certificate
Academic Transcript
Two ID/Passport Photos
Certificate of Conduct
SAQA Evaluation
Identity Document / Passport
School Results
Marriage Certificate
Name of Officer : _______________________
Signature : ____________________________
Office Stamp
8

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