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Application Forms final

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202 views4 pages

Application Forms final

Form

Uploaded by

endyapleni2007
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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APPLICATION FORM FOR ACADEMIC ADMISSION 2025 ID PHOTO BE

NAME OF QUALIFICATION (3-year Diploma in Nursing(R171)) AFFEXED HERE

GUIDELINES AND INFORMATION FOR APPLICANTS:


NO DOCUMENTS TO BE ATTACHED tick√

1. Application Form

2. Certified copy of National Senior Certificate

3. Certified Grade 12 mid-year June results for Scholars.

4. For a Study Leaver – A Recommendation Letter and Proof of approved Study Leave

5. Certified copies of Identity Document

6. Certified copy of Marriage Certificate

7. Curriculum Vitae with reliable contact numbers and clear physical address indicating the
town/farm/ village of origin AS A CATCHMENT AREA

8. Application must be accompanied by proof of residence (letter from a ward councilor ,valid Lassie
agreement)

9. a) A non-refundable application fee of R50 must accompany the application form.

b) Original deposit slip or EFT slip must be attached to the application form and keep a copy by
the applicant for future reference

c) The reference should reflect your surname and name(s)


BANKING DETAILS:
ACCOUNT NAME: LILITHA COLLEGE OF NURSING
BANK: FIRST NATIONAL BANK
BRANCH: BHISHO

BRANCH CODE: 210619

ACCOUNT NUMBER: 62407182229

REFERENCE: APPLICANT’S SURNAME AND FULL NAME


SECTION A: PERSONAL DETAILS

SURNAME: …………………………………………… INITIAL(S)…………..……… TITLE…………...

FULL NAME(S): ….……………………………………………………………..…………………………................

MAIDEN NAME: (if applicable) ……………………………….……………………………………………………...

ID. NO.:

DATE OF BIRTH: d d m m y y y y

GENDER: Female Male

MARITAL STATUS: SINGLE MARRIED DIVORCED WIDOWED

HOME LANGUAGE: ………………………………….. RELIGION:……………………………….…………..

PHYSICAL ADDRESS:
…………………..…………………………………………………………………………………………….

………………………………………………………………………………………… POSTAL CODE: …………

CONTACT NO(S): ………………………………… Alternative number…………………………………………..

DISRICT MUNICIPALITY:……………………………………………………….…………………………………….

LOCAL MUNICIPALITY: ……………………………………………………WARD NUMBER: …………..………

EMAIL ADDRESS…………………………………………………………….………………………………………..

RACE GROUP: BLACK WHITE COLOURED INDIAN

NATIONALITY: SOUTH AFRICAN CITIZEN Y N

FOREIGNER WITH PERMANENT RESIDENCE PERMIT (Foreign applicants must submit proof of permanent
residence): PASSPORT NUMBER: ……………………………………………...... EXPIRY DATE: ..……….………..

SECTION B: DISABILITIES / SPECIAL NEEDS

DO YOU HAVE ANY DISABILITIES / SPECIAL NEEDS? YES NO

If yes, please indicate:

VISUAL IMPAIRMENT: HEARING IMPAIRED: PHYSICAL IMPAIRMENT: OTHER

If other please specify: ………………………………..…………………………………………….…………………..

Please provide more information if you have ticked any of the above: ………………….……………………………

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SECTION C: PROPOSED LOCATION

NAME OF CAMPUS: …………………………………………………………….........................................

SECTION D: SCHOOL LEAVING DETAILS

NAME OF SCHOOL: ……………………..…………………………….YEAR COMPLETED: …………..................

SOUTH AFRICAN APPLICANTS ONLY

Very important: If you are currently in Grade 12, please submit a certified copy of the following results:

June Grade 12 results or Final Grade 12 results

Please ensure that you list the following:

• Grade or level of achievement for All subjects


• Clearly indicate whether the language is home / 1st additional / 2nd additional
Minimum Requirements for the Diploma in Nursing:
NSC Subjects NSC % APS Allocated LEVEL
English (Compulsory) 50-59% Minimum (4)
Biology/Life Sciences (Compulsory) 50-59% Minimum (4)
Any one of the other SA languages
Any 5 of the following
Physical Science
Mathematics
Mathematical Literacy
Life Orientation
Geography
Agricultural Science
Computer Applications Technology
Minimum score 24

SECTION E: DECLARATION BY AN APPLICANT


If I am admitted as a student to the College, I undertake to:

1. Perform such work as may be assigned to me by members of staff and to conform to all the rules and regulations
laid down by the College.
2. Acquaint myself with all the rules, regulations and instructions applicable to the qualification for which I enroll; I
have also acquainted myself with the fees payable as stipulated by the College.
3. I am aware that my application is valid only if it complies with the regulations of the qualification concerned,
notwithstanding the acceptance of this registration by the College.
4. The information furnished by me herein is to the best of my knowledge true, correct and complete.
5. An applicant who submits any document in support of this application, which contains a false statement, is altered
or forged, will be criminally prosecuted.
6. The findings of the Disciplinary Committee will be communicated to all other tertiary institutions in the country.

Signature of
Applicant………………………………………...……………………Date…………………………………………

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SECTION F: APPLICANT’S PARENT/LEGAL GUARDIAN INFORMATION

Details of Parent/Legal Guardian:


SURNAME: ………………………….………………….. INITIAL(S)……… TITLE……………...……...
FULL NAME(S): …………………………………………………….…………………………………............
ID. NO.:……………………………………………………….

PHYSICAL ADDRESS:
…………………….………………………………………………………………………………………….
…………………………………………………………………… POSTAL CODE: …………….………
CONTACT NO (S): …………………………. EMAIL: ……………………………………………
RELATIONSHIP TO APPLICANT (e.g. Father, uncle, aunt etc.):
………………………….……………………...
EMPLOYER’S NAME: ………..…………………………………………..………………………………
EMPLOYER’S ADDRESS: …………………..…………………………………………..………………
POSTAL CODE: ……………………
WORK TELEPHONE NUMBER:…………………………………………………………………………

OFFICIAL USE ONLY

Photo Attached:

Certificate Attached:

Proof of Payment:

Surname & Initials:

Proof of Address:

Student Number:

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