APPLICATION FORMS FOR PRE-SERVICE/IN-SERVICE CANDIDATES.

CERTIFICATE/DIPLOMA PROGRAMMES.

Attach photo here

STUDENT NUMBER

APPLICATION FORM/CONTRACT.

Please complete this form and send it back to the EXECUTIVE DIRECTOR, SHIRAMED MEDICAL
INSTITUTE.

The form should be filled in BLOCK letters. Attach copies of results slip/certificate,
ID/Passport/Birth certificate. Attach Application Fee in form of a Banking slip or Bankers
Cheque of 180.00 for Namibians and 260.00 for non-Namibians.

SECTION A: Applicants Personal Particulars.

1. Names as per ID/Passport/Birth Certificate------------------------------------------------------------.
2. Postal Address-------------------------------------Town----------------------------------------------------.
3. Gender. M/F---------------------------------------------------------------------------------------------------.
4. Nationality------------------------------------------------------------------------------------------------------.
5. Marital Status--------------------------------------------------------------------------------------------------.
6. Date of birth---------------------------------------------------------------------------------------------------.
7. Home Language-----------------------------------------------------------------------------------------------.
8. Mobile telephone contact----------------------------------------------------------------------------------.
9. Region of Origin-----------------------------------------------------------------------------------------------.
10. If not, Namibian provide country of origin--------------------------------------------------------------
SECTION B: Course application details.
1. 1ST Choice------------------------------------------------------------------------------------------------------.
2. 2nd choice-------------------------------------------------------------------------------------------------------.

SECTION C. Applicants Educational Background.

1. Name of the school attended-----------------------------------------------------------------------------.

2. Year of examination-----------------------------------------------------------------------------------------.
3. Highest Grade Passed---------------------------------------------------------------------------------------.
4. Please attach latest examination results.
5. Grade 12 learners August results. ----------------------------------------------------------------------
6. Previous educational qualifications already possessed---------------------------------------------.
7. Any outstanding results-------------------------------------------------------------------------------------.

SECTION D. Employment History.

1. Name of the employer------------------------------------------------------------------------------------.

2. Address of the employer----------------------------------------------------------------------------------.
3. How many years have you worked----------------------------------------------------------------------?
4. Position held--------------------------------------------------------------------------------------------------.
5. Duties performed--------------------------------------------------------------------------------------------.
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SECTION E: Health Questionnaire.

1. Do you suffer from any disabilities? If yes please clarify--------------------------------------------.
2. Do you suffer from any illness? If yes please clarify --------------------------------------------------
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3. Do you take alcohol, smoke or take any psycho-active element?---------------------------------
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SECTION F:
Describe why do you want to become a nurse?----------------------------------------------------------------
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SECTION G: Next of kin/legal guardians-------------------------------------------------------------------------

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SECTION H: Sponsorship.
Full names of the sponsors if any-----------------------------------------------------------------------------------.

Address-------------------------------------------------------------------------------------------------------------------.

Cell phone Number----------------------------------------------------------------------------------------------------.

Address of the work place------------------------------------------------------------------------------------------.

KINDLY NOTE.
Kindly attach the following documents in your application and verify,
A. Certified copies of your ID/passport or birth certificate.
B. One recent passport photo.
C. Certified copies of all academic certificates/ results.
D. Evidence of payment (1). Application fee of 180.00, late application 200.00.

(2). Student card 90.00.

DECLARATION BY THE SPONSOR.
Name------------------------------------------------------------------ and i/we do hereby agree to pay the
fees of student----------------------------------------------------------------------------------------------------- as
agreed by the Director of SHIRAMED MEDICAL INSTITUTE.

Name: ----------------------------------------------------------------------------------------------------------------

ID/NO: -----------------------------------------------------------------------------------------------------------------

We also agree fees once paid are subject to SMI FINANCIAL RULES AND REQULATIONS.

DECLARATION BY THE STUDENT.

1. I declare that I have read the instructions for completing my enrolment form and the
information given is true to the best of my knowledge and fully understand that any
information found to be false will lead to automatic disqualification from
consideration/prosecution.
2. I fully agree to abide by the rules and regulations and the contract once signed cannot
be cancelled once learning has started.
3. I agree to meet all enrolment deadlines and make payments of all fees arising from this
enrolment by their due date.
4. I authorize the Nursing Education Institute to transfer, disclose any information
provided by me or information obtained in connection to with these enrolment to all
relevant institutions like Nursing council of Namibia, Ministry of health and social
services, NQA, NQF, National council for higher education, other institutions offering
similar courses as demeaned necessary.
5. I hereby authorize SMI verify any documents which accompanies this application with
the issuing body.
6. I understand that I am required to keep the original documents provided for at least 6
months period following the submission of the form, and that I may be required to
produce this as a result of SMI random audit process.

Signed--------------------------- on this-------------day of----------month of---------------------------.

FOR OFFICIAL USE ONLY.
1. Total points in grade 12-------------------------------------------------------------------------------------.
2. English-----------------------------------------------------------------------------------------------------------.
3. Biology----------------------------------------------------------------------------------------------------------.
4. Mathematics/Physical Science-----------------------------------------------------------------------------
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5. Course admitted to------------------------------------------------------------------------------------------.
6. Admission confirmed by------------------------------------------------------------------------------------.
7. Deposit slip/bankers Cheque------------------------------------------------------------------------------.
8. Remarks----------------------------------------------------------------------------------------------------------
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Executive Directors Signature-----------------------Date/-----------/--------------20-----------------.

OFFICIAL STAMP OF SMI.

BANKING DETAILS

Account Name: Shiramed Medical Institute

Type of Account: Current
Account Number: 62270788767
Registration Number: 2018/0402
Bank Name: First National Bank (FNB)
Branch Name: Katima Mulilo
Branch Code: 280475
Swift Code: FIRNNANX