Zamukulungisa Online Application Form – Fill Out and Use This PDF

Application for Admission for the Year 2013

PLEASE READ THE FOLLOWING INSTRUCTIONS BEFORE COMPLETING THE FORM

1.This is only an application for admission to an academic programme. Complete the accommodation application form (if accommodation is required).

2.To avoid delay in processing, all information required must be illed in as accurately as possible.

	3.	Indicate your campus of preference below.	Ofice Use
	4.	Address your application to the Registrar at the postal address as indicated below.

Application fees and closing dates: - a non-refundable application fee must accompany the application

				Application Fee		Late Application Fee
South Africans applicants				R100.00		R190.00
International and SADC applicants				R180.00		R350.00
Faculty				Closing Date		Closing Date			Closing date for walk-ins
Health Sciences				30 September 2012		31 October 2012
Science, Engineering and Technology				31 October 2012		30 November 2012
Business, Management Sciences and Law				31 October 2012		30 November 2012			11 January 2013
Education				31 October 2012		30 November 2012
Delivery Site	Selection		Address				Method of Payment
Nelson Mandela							Bank Deposit: First National Bank
			Private Bag X1, Mthatha, 5117. Tel: 047 502 2443/8				Walter Sisulu University, Acc. No.: 62099126601
Drive
							Branch Code: 210521
Zamukulungisa			Private Bag X6030, Mthatha, 5100. Tel: 047 501 1400
							Bank Deposit: First National Bank
Ibika			Private Bag X3182, Butterworth, 4960. Tel: 047 401 6000
							Walter Sisulu University, Acc. No.: 52120232526
Queenstown			P.O. Box 876, Queenstown, 5320. Tel: 045 807 8702
							Branch Code: 210121
Chiselhurst			P.O. Box 19712, Tecoma, 5214. Tel: 043 709 4000
Potsdam							Bank Deposit: First National Bank
			Private Bag X1421, East London, 5200. Tel: 043 708 5200				Walter Sisulu University, Acc. No.: 55990711126
College Street
							Branch code: 210121

Postal orders to be made payable to: Walter Sisulu University

OFFICE USE ONLY: Selection/Assessment results Mark with ‘X’

Choice 1	Admitted		Rejected			Waitlisted			Interview / test
HOD: Surname:				Initials:			Interview / test date:
Signature:				Date:
Choice 2	Admitted		Rejected			Waitlisted			Interview / test
HOD: Surname:				Initials:			Interview / test date:

SECTION A: Personal Details

Mr/Mrs/Miss/Dr/Prof

Surname

Initials

First Name(s)

Maiden Name (if applicable)

Date of Birth

I.D. Number (SA Identity No. Only)

Gender/Race

Male

Female

Black

White

Coloured

Indian

Other

Marital Status

Single

Married

Divorced

Widowed

Home Language

Religion

SA Citizen

Y

/

N

If NOT a South African Citizen, please tick one of the options below:

(A) African (African countries)

(F) Foreign (outside Africa)

(R) Refugee Permit

(E) Exchange Student

(N) Permanent Resident

Passport No.

Study Permit No.

Study Permit Expiry Date

Occupation

Postal Address

Postal Code

Province (if residing in SA)

Telephone No.

Int. Code +

Number

Mobile (Cellular) No.

Int. Code +

Number

Email Address

Physical Address (Street or Administrative Area - NOT P.O. Box)

SECTION B: Next of Kin Details (Parent or Guardian)

Relationship

Parent

Guardian

Initials

Surname

Date of Birth

Postal Address

Telephone No. (H)

Int. Code +

Number

Telephone No. (W)

Int. Code +

Number

Mobile (Cellular) No.

Int. Code +

Number

Email Address

SECTION C: What are you doing this year?

University

Teachers College

Nursing School

FET College

Working

Grade 12

Other

If Other, specify

SECTION D: Physical Limitation

Are you Physically Challenged

Y

/

N

If yes, please specify below:

Blind or Partially Sighted

Hearing (even with hearing aid)

Communication (talking, listening)

Physical (moving, standing, grasping)

Intellectual (dificulties in learning)

Emotional (behavourial or psychological)

Multiple/Other (Please specify)

SECTION F: Matric / Grade 12 Information

Current Grade 12 Learners

Examination Centre No.

Exam No.

If you have already completed Matric/Equivalent, please complete this section and attach a certiied copy

Matriculation/Equivalent Status Endorsement

Senior Certiicate

Foreign Qualiication

Other

Other, specify

School Name

Postal Address

Postal Code

SECTION G: Application for Recognition or Exemption of Subject

If yes, please obtain and complete the Exemption Form from Student Enquiries

SECTION H: Declaration by Prospective Student

1.I declare that all particulars given by me on this application form are true and correct.

2.I agree that any misrepresentation due to the information provided on this form or the withholding of information shall cause this application to become null and void at the discretion of the University without prejudice to its rights.

3.If my application is successful, I undertake to:

a.Comply with the rules and regulations of the University.

b.Inform the Registrar immediately in writing of any change of address.

c.Acquaint myself with the rules and general regulations relating to the programme to which I am admitted.

4.I am fully aware that the University is under no obligation to provide me either with inancial assistance or accommodation.

5.I acknowledge that all fees have been determined by the Council of the University.

6.I agree that the relevant fees will be paid as indicated in the Prospectus of the University by the due date. If such fees are not paid, I acknowledge the rights of the University to cancel my registration at any time and to demand payment of the amounts owing by me and/or my parent/guardian.

7.Should I, during the course of my studies at the University, sustain any injuries or contract any illness or suffer any loss or damages, I hereby undertake not to institute any claim against the University on account thereof, irrespective of the cause of such damage or loss. In the event of my death during the course of studies, this undertaking shall be binding on the executor of my estate and my heirs and successors-in-title. Under the circumstances referred to above, I or my executor, administrator, heirs and succesors-in-title, hereby indemnify the University in respect of any damages suffered by me arising from any causes referred to above.

Date

Signature of Student

SECTION I: Declaration by Parent/Guardian

I, (full names) _____________________________________ hereby grant permission for the declaration and undertaking made by the applicant, and

I accept joint and several liability as co-principal debtor with the applicant for the payment of all fees due by him/her to the University.

Signature of Parent/		Date
Guardian
SECTION J:
If you have registered to write the National Benchmark Test or have already written the test, please provide your reference
number: …………………………………………………………………………..
Have the documents listed hereunder been attached?						CHECKLIST
					YES				NO

1.Matriculation endorsement, senior certiicate or equivalent qualiication.

2.Your transcript of academic record or certiicate of conduct in respect of studies completed at any other educational institution, if applicable.

3.Certiicates, diplomas or degrees previously obtained.

4.Certiied copy of Birth certiicate or ID document.

5.Marriage or divorce decree for different surnames.

6.For conditional or mature age exemption, submit in person all original documents listed in 1, 2, 3, 4 & 5.

7.The original copy of the study permit or proof of permanent residency must be submitted by all foreign applicants.

8.The identity document of parent or legal guardian.

9.International students should attach SAQA results.

	Proof of submission of Academic Application Form for 2013
Surname:	Initials:	ID:
Proposed course of study: 1
2
Campus/site:
Date of submission:	Place: