THUTO BOPHELO NURSING ACADEMY A P P L I C …

1 S1074 FA0014 THUTO BOPHELO NURSING ACADEMY AAPPPPLLIICCAATTIIOONN FFOORRMM PPEERRSSOONNAALL PPAARRTTIICCUULLAARRSS Title: Surname: Names: Residential Postal Address: Suburb: Town: Address: Suburb: Town: Telephone Own: (home) (cell) Numbers(s): Spouse: (work) (cell) Identification Number: Date of birth: Country of Birth: Nationality: City of birth: Gender: Male: Female: Marital Status: Married Single Widow/Widower Divorced Are you currently Y N Where?

2 Date (s): working? Name of contact person: Tel nr: EEDDUUCCAATTIIOONNAALL QQUUAALLIIFFIICCAATTIIOONNSS Highest standard passed/ qualification obtained: Year: School attended/ Institution Did you do a pre-course in NURSING ? If YES, please include copy of certificate Name of course: Name of institution KKNNOOWWLLEEDDGGEE OOFF LLAANNGGUUAAGGEESS LANGUAGE WRITE READ SPEAK English Other MMEEDDIICCAALL FFIITTNNEESSSS Mark each question with a X in the appropriate block YES NO YES NO a. Do you suffer from any physical illness, sensory or physical disabilities f Do you suffer from any type of psychological illness depression, bi-polar, epilepsy, etc.

3 If YES, please specify If YES, please specify. b. Have you ever experienced any back problems? g Are you on any type of chronic medication (hypertension, insulin, etc) If YES, please specify condition and any treatment received. If YES, please specify. c. Have you ever sustained an occupational injury? h Do you use any addictive substances (alcohol, pills, etc) If YES, was it certified as such? If YES, please specify. Did you receive any compensation for the injury? I Are you currently pregnant or plan to start a family during future training? d. Do you smoke? RREEFFEERREENNCCEESS ((PPeeooppllee wwhhoo kknnooww yyoouu)) NAME OF REFERENCE TELEPHONE NRS RELATIONSHIP ( friend/relative) DDEECCLLAARRAATTIIOONN H e r e b y I , t h e u n d e r s i g n e d , d e c l a r e t h a t t h e a b o v e p a r t i c u l a r s a r e c o m p l e t e a n d c o r r e c t.

4 _____ _____ S I G N A T U R E D A T E T h i s a p p l i ca t i o n m u s t b e a c c o m p a n i e d b y : 6 c e r t i f i e d c o p i e s o f t h e e a r n e r s i d e n t i f i c a t i on d o c u m e n t 6 Ce r t i f i e d c o p i e s o f l e a r n e r s H i g h e s t Q u a l i f i c a t i o n FFoorr ooffffiiccee uussee oonnllyy.

5 CCHHEECCKKLLIISSTT 6 COPIES ID/PASSPORT LESARNER CONTRACT MARRIAGE CERTIFICATE INDEMNITY FORM 6 COPIES GR 12 CERTIF/ HIGHEST QUALIFICATION STUDY PERMIT PROOF OF RESULTS SAQA EVALUATION PROOF OF DEPOSIT PAID LETTER OF SUPPORT:FRGN AFFRS Learner nr Course nr Date Course number