ENROLMENTS/REGISTRATIONS FORM

ORDINARY CERTIFICATE & DIPLOMA

ACADEMIC BACKGROUND

Qualifications, which you have ----------------------------------------------------------------------------------------------------------------------

Qualifications, which you are seeking --------------------------------------------------------------------------------------------------------------

Course by distance learning

Level: Certificate: -----------------------------------------------------------------------------------------------------------------------------------------

Level: Diploma: ------------------------------------------------------------------------------------------------------------------------------------------

PERSONAL DATA

First name: ---------------------------------------------------------Surname: ----------------------------------------------------------------------------

Date of birth: ----------------------------------------Country------------------------------------Sex: F -------------- M --------------------------

Nationality-------------------------------------------------Postal address-------------------------------------------------------------------------------

Town/City-----------------------------Region---------------------------------Post Code---------------------------------------------------------------

Marital status -----------------------------------------------Number of Children----------------------------------------------------------------------

Tel (area code)----------------------------------------------Fax (area code) -------------------------------------------------------------------------

Mobile phone no.------------------------------------------------------Email-----------------------------------------------------------------------------

PASSPORT DETAILS: If you do not have a national passport please provide your national ID details below

Passport or ID number -----------------------------Date of issue-----------------------------Expiry date-----------------------------------------

Place of issue----------------------------------------------Issue by which government------------------------------------------------------------

Resident permit number (if applicable) ------------------------------------------------------------------------------------------------------------

DECLARATION

I confirm that to the best of my knowledge the information given on this form is correct and complete.

Signature of applicant--------------------------------------------------------------------Date-----------------------------------------------------------

OFFICE USE ONLY

Date sent------------------------------------------------Date application received----------------------------------------------------------------

Application number -------------------------------------------------------------------------------------------------------------------------------------