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2017

_____________________________________________________________________________________

Student Application Form


_____________________________________________________________________________________

Under - Graduate
Post - Graduate

The Registrar Academic


Tel : 012 521 4111/4979/3357
Fax : 012 521 5732
PO Box 60, Medunsa, 0204

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 :

Account Number : 071 244 395


Reference: YOUR ID NUMBER
Student Number
For Office Use

1.

2.

Academic Year
2017

ACADEMIC DETAILS

A.

1st
Choice
2nd
Choice
Mode of
Study

Sefako Makgatho
Health Sciences
University
020909

Qualifications you intend to follow (e.g. MBChB, B.Sc.)


Degree / Diploma
Study Level
For office use
For office use
For office Part
use
Time

Full
Time

B.

For office Block


use
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

STUDENT APPLICATION FORM


B.
12.

Marital Status

14.

PERSONAL DETAILS OF APPLICANT (cont.)


13.

Gender

Home Language /
Mother Tongue

15.

16.

Occupation

17.

18.

Residential or
Physical Address
(not school address)

Religion /
Church
Affiliation
Physical
Impairment
(e.g. blind)

19.

20.

Code

Telephone No.

Fax No.

Cell No.

Email

21.

Citizenship /
Nationality

23.

Province /
State

Male

Code

Postal
Address

C.

Female

DETAILS / HEMIS (These Stats are Compulsory)


22.

Ethnic
Group / Race

24.

Rural /
Urban / PeriUrban

STUDENT APPLICATION FORM


D.
25.

Examination
Date

27.

Examination
No.
Senior Certificate
Type
School Name

28.
29.
30.
31.
32.

MATRICULATION DETAILS
26. Highest Grade
(standard if
Applicable)

Examination Department
(e.g. Gauteng, etc.)
Last
December
June
Examination Grade 11
Grade 12
Subjects and
Subject
results of
last
examination

For office use


For office use
For office use
For office use

December
Grade 12
Code

Symbol/Level

For office use


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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
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

Period

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RESIDENTIAL APPLICATION (OPTIONAL)

Would you like accommodation on campus


Student housing with catering

Please Note that accommodation on campus is not guaranteed

YES

NO

YES

NO

STUDENT APPLICATION FORM


FINANCIAL AID (OPTIONAL)

G.
37.

H.

Do you require and qualify for financial assistance

NO

PARTICULARS OF PARENTS/GUARDIAN/ SPOUSE/ NEXT OF KIN

38.

Title

39.

Residential Address
(not postal address)

40.

YES

Initials

Surname

Relationship

Code

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?

Cell phone
YES

NO
Staff
No.

STUDENT APPLICATION FORM


DECLARATION

I.

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


_______________ 20.
Signature of Applicant : _____________________________________________
Date : _______________________
Signature of Parents/Guardian/Spouse : _______________________________
Date : _______________________

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

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