ANNEXURE A: STUDENT APPLICATION FORM

APPLICATION FOR REGISTRATION AS A STUDENT FOR A POSTGRADUATE DIPLOMA

PROGRAMME

Instructions: Please complete all required information

Tick (√) the relevant box

PROGRAMME TO BE FOLLOWED COURSE CODE

OFFICE USE
Child Nursing Nephrology Nursing

Community Health Nursing Occupational Health Nursing

Critical Care Nursing (Adult) Oncology and Palliative Nursing

Critical Care Nursing (child) Ophthalmic Nursing

Emergency Nursing Orthopaedic Nursing

Forensic Nursing Perioperative Nursing

Infection prevention and control Primary Care Nursing

nursing

Mental Health Nursing Health service management

Midwifery Nursing Education

PERSONAL DETAILS OF LEARNER

(Please write your names exactly as they appear in your S A Nursing Council
identity document.) reference number (if you already have one)

Surname (family name) Postal address

Given names (in full)

Maiden name (if applicable)

Year Month Day
Date of birth Postcode

S A Identity number Residential address (physical address at HOME)

(*)
The following passport information is required ONLY if you
do not have a South African identity document.

(*)
OR Passport number

(*)
Country of issue Postcode
Female Male
Gender (tick one block) Mobile phone number ( )
School Other
Highest educational standard grade Home phone number ( )

Email address: Fax number ( )

DETAILS OF PROGRAMME TO BE FOLLOWED
Name of Nursing
Education Institution
Which year of the
Date of commencement/ Year Month Day programme will you be 1st 2nd 3rd 4th
resumption of training entering? (tick one block) Year Year Year Year

LEARNER STATISTICAL INFORMATION (unless otherwise indicated, mark ONE block in each section with a cross “X”)
Eastern Cape EC Mpumalanga MP
Province in which you live Free State FS Northern Cape NC
Gauteng GP North West NW
KwaZulu Natal KZN Western Cape WC
Limpopo LP
Employment equity code Black African BA Indian/Asian IA
(Department of Labour codes) Coloured Person CP White WH
South Africa SA Zaire ZAI
Nationality Angola ANG Zambia ZAM
Botswana BOT Zimbabwe ZIM
Lesotho LES Rest of Africa ROA
Malawi MAL
Mauritius MAU Asian Countries AIS
Mozambique MOZ Australia and New Zealand AUS
Namibia NAM Central and South American SOU
Seychelles SEY European Countries EUR
Swaziland SWA North American Countries NOR
Tanzania TAN Other and rest of Oceania OOC
Afrikaans AFR Sesotho SES
Home language English ENG Setswana SET
isiNdebele NDE siSwati SWA
(Predominantly used home isiXhosa XHO South African Sign Language SASL
language if more than one) isiZulu ZUL Tshivenda TSH
Sepedi SEP Xitsonga XIT
Other Please specify: OTH
SA Citizen SA SA Permanent Resident PR
Resident status Dual (SA plus other) DU Other OT
Please specify other: Please specify
Employed – on study leave 01
Socioeconomic status Not working – student 06
None 00
Disability status Sight (experience problems even when wearing glasses /
01
contact lenses)
(If necessary, please select Hearing (experience problems even when wearing hearing aid or
02
more than one item under with implant)
this section) Communication (talking / listening) 03
Physical (moving / standing / grasping) 04
Intellectual (difficulties in learning / retardation) 05
Emotional (behavioural or psychological) 06
Other (not mentioned above) 09
DECLARATION BY STUDENT
Answer these four questions with a definite “YES” or “NO” by making a tick () in the appropriate block. If the reply to any of
the questions is “YES”, full particulars must be submitted together with the application.
WARNING:
An incorrect answer to any of these questions could lead to disciplinary action taken against you.
If you are in doubt as to how to answer one or more of these questions, please contact the Council for assistance.
1. Are you currently registered with Council as a Professional nurse or General nurse with Midwifery
YES NO
2. Have you been terminated from training? If yes attach Notice of termination from previous NEI YES NO
3. Have you ever been found guilty of an offence in any country? YES NO
4. Is a charge of an offence pending against you in any country? YES NO
5. Are you studying this course full time or part time YES NO

NB. IF YOU HAVE ANSWERED YES ON SECTION 3 AND 4 UNDER DECLARATION, PROVIDE THE DETAILS IN SEPARATE PAGE AND THE
REPORT SHOULD ADDRESS THE WHAT, WHERE, WHEN, HOW, WHO AND WHY

ATTACHMENTS
The application should be accompanied by the following certified documents:

1. A certified copy of your identity document or passport (the details of which are reflected in this application)
2. National Senior Certificate
3. Mature age conditional age exemption where applicable
4. In case of international students, a SAQA evaluation certificate and a student permit
5 A marriage certificate or affidavit in case of inconsistency in the names of the applicant
If either of the above documents is in a language which is not an official language of South Africa, a sworn translation of the document,
made by a certified translator, must accompany the document.

I certify that the information on this application form is true and correct.

Signature of applicant Date / / Total amount paid R ,

FEES PAYABLE

The fee payable by the student for registration is as published in the Board notice issued by Council. This amount must be paid / deposited
into the Council’s bank account by the Nursing Education Institution on behalf of the student. Use the NEI’s number followed immediately
by the payment type code REGFLEN as reference for the payment.

The student registration fee is correct from 1 January every year and VAT inclusive. Payments received by the Council before this date will
be charged at the old rate.

N.B.: An application must be submitted within 2 months (60 days) of commencement date of education and training.
A penalty fee per applicant will be levied on the NEI for late submission of student application.

INCORRECT AND INCOMPLETE FORMS WILL NOT BE ACCEPTED

DECLARATION BY DESIGNATED PERSON IN CHARGE OF NURISNG EDUCATION AND TRAINING INSTITUTION

I certify that I have checked this application for completeness and accuracy and to the best of my knowledge it is true and correct
(based on the information supplied to me).

NB: ANY PERSON THAT MAKES A FALSE DECLARATION OR MISREPRESENTS THE FACTS OR INFORMATION GIVEN IN THIS
DECLARATION MAY BE CHARGED WITH AN OFFENCE IN TERMS OF SECTIONS 46 AND 54 OF THE NURSING ACT, 2005 (ACT NO.
33 OF 2005).

Signature of designated person

in charge of education and training Date / /

Affix the NEI Stamp in the block below:

S A Nursing Council – Contact Details

The Registrar
South African Nursing Council
Private Bag X132
PRETORIA
0001

Tel: 012 420-1000

Fax: 012 343-5400 (24-hour)
Email: [email protected]
Website: www.sanc.co.za