Application Form: NWU-Puk Rugby Institute

(Complete and fax to: 018 299 2430)

A. Personal Information

Surname Name

ID No. / Passport No. Birth Date Y Y Y Y M M D D

Street Address Postal Code

Postal Address Postal Code

Tel No. Area Code No. Fax No. Area Code No.

Cell No. E-mail

B. Rugby Details

School Position

Height Weight

Three best rugby achievements within the last two years (teams represented and time periods)

Rugby reference, name and contact details

Name School

Tel No. Area Code No.

C. Academic Achievements

Subject
1 Percentage 5 Percentage

2 Percentage 6 Percentage

3 Percentage 7 Percentage

4 Percentage 8 Percentage

D. Planning

Your intended field of study

E. Choice of Accommodation (Please ensure that you have completed a university and hostel residence application form)

NWU-Puk Hostels Private NWU-PUK-Rugby Institute Housing

Signature
Date Y Y Y Y M M D D

NORTH-WEST UNIVERSITY
YUNIBESITI YA BOKONE-BOPHIRIMA
NOORDWES-UNIVERSITEIT
POTCHEFSTROOM CAMPUS

6959BKA Rugby Instit App.indd 1 5/14/09 2:40:54 PM