£G LIMPOPO HEALTH LIMPOPO COLLEGE OF NURSING APPLICATION FOR ADMISSION DIPLOMA IN NURSING (R.171 OF 8 MARCH 2013) ‘A: PERSONAL INFORMATION (PLEASE PRINT) +(Certified of 1.0, and Marriage Certificate must be attached) Maiden Name (If Applicable) G ‘| A2names |P IN lt lel [Mul falmmlald ‘A3. Identity No. [Date of birth Sb T3olu ols Tcfolul2 fo Is Jo io Is A4. Are you a South African Citizen? Yes | |No A.5 Gender | Male ‘A.6 Have you been convicted of criminal offensse?, Yes A.7\s there any criminal charges pending against you? Yes No ‘A.8 Do youa disability? Yes No A.9 Did you attach a deposit slip/proof of payment? Yes _||No A.10 Date of payment and reference number ta (1p |2072. 8 N°2433450 | Yes No B: HOW DO WE CONTACT YOU B.1 Postal Address District B.2 Residential Address POHL 6B Moreen Gyan Local Municipality Kemeravt 5958 Greater Gyan) Postal Code: [0 |e |2 | 6 B.3 Name of a Relative Taybcal Tel. No. Olalzlel vel solo]y | Name of a Relative Wu ja\neen | Tel. No. olaluleleh |e lalla ‘Applicant's telephone/cell no. ol<|i faz uehi fe [e Email address }ovtu [Wie |mimla ld] Plaltlel\ 1o}2 13 |@lo ma ft (¢: ACADEMIC DATA (CERTIFIED PROOF MUST BE ATTACHED) C.1 Have you passed grade 127 Yes [1-[No C.2In which year did you pass Grade 12? 1021 Yes No €.3 Do you have an exemption or bachelor's degree? Yes No |x CA Have you completed the attached rating scale? Yes |b [No D: DECLARATION | dectare that the above particulars and infomation given with my application is completed and true, and that | am aware that any purposeful withholding of information supplied by me could lead lo Immediate disqualification. Signature of Applicant: \W\- Pate! Date Lied ello 2] Page 1 of 2 el Powered by (9 CamScannerA L {Sh . IMPOPO. RATING SCALE "ore = _ Ratting scale to be completed by all applicants HEALTH who have Senior Cerificate with M- Score/ Matric Exemption OR National Senior Certificate with Bachelor's degree A FULL NAME OF APPLICANT_(7<\¢\_(\WuVieinem ad 1D. NUMBER 0 3356 ula G a fu [zo Iv 0 CIRCLE YOUR SUBJECT UNDER THE APPROPRIATE SYMBOLILEVEL AND TOTAL AT THE BOTTOM OF THE SCALE NB: LIFE ORIENTATION SHOULD NOT BE COUNTED. PERCENTAGE (%) 80 -100% | 70-79% | 60 - 69% | 50-59%] 40-49% |30-39%|0-29% LEVEL x 6 5 4 3 2 1 HG (HIGHER GRADE) A 8 c D F G | SG (STANDARD GRADE) A B c E F ENGLISH 7 [6 © |4 3 [2 [1 LIFE SCIENCES/BIOLOGY 7 [6 [5 |4 (D [2 [4 | PHYSICAL SCIENCES 7 [6 [5 [4 [3 91 MATHEMATICS 7 [6 [5 [4 [3 Ol4 MATHEMATICAL LITERACY 7 [6 [5 [4 [3 |2 [4 ‘AFRIKAANS 7 [6 [5 (4 [3 |2 [1 NORTHERN SOTHO/SEPEDI 7 [6 [5 [4 [3 [2 [4 TSONGA 7 [6 [5 |4 (@ [2 [4 VENDA 7 [6 [5 [4 [3 [2 [1 AGRICULTURAL SCIENCE 7 [6 [5 [4 @ [2 |1 GEOGRAPHY 7 [6 [5 [4 [3 2 [1 HISTORY 7 [6 [5 [4 [3 [2 [4 INFORMATION TECHNOLOGY 7 [6 [5 [4 [3 [2 [4 COMPUTER APPLICATION TECHNOLOGY 7 [6 [5 (4 [3 |2 [1 ACCOUNTING 7 [6 [5 [4 [3 2 [1 ECONOMICS 7 |e [5 [4 [3 [2 [1 BUSINESS STUDIES 7 [6 [5 [4 [3 [2 |1 CONSUMER STUDIES/HOSPITALITY (CIRCLE THE 7 6 [5 |4 (3 [2 |4 APPROPRIATE ONE) DRAMATIC ARTS/VISUAL ARTS/CULTURE AND ARTS (CIRCLE 7 [6 |5 [4 [3 [2 |1 ‘THE APPROPRIATE ONE) ENGINEERING GRAPHICSAND DESIGN 7 [6 [5 [4 [3 [2 |4 MUSIC 7 (6 [5 [4 [3 [2 [4 OTHER 7 [6 [5 [4 [3 [2 [4 REQUIRED: MINIMUM 24 POINTS TOTAL SCORE: ApPLicANT’s signature: N\ fate] Page 2 of 2 aT Powered by 3 CamScannersusriouni SOHON CONTIFECNTE 7 dasteanae eoutee oasesie nc ita SS0FIca Ber 1 i oad coca op NONCE OF PERSONAL PARTICULARS ‘i am aber Powered by 9 CamScannerTYANI MUNICIPALITY GREATER faa 0398 011500 “4 meas e12 2068 Sen OFFICE OF THE MUNICIPAL MANAGER en. se ef ena. :CHABALALAT.V pate: 15/12/2022 TO WHOM IT MAY CONCERN ‘his serves to confirm that : MUHAMMAD PATEL identity number/Passport/Registration no : 030407 6042 080 A registered owner/occupant of house number: 333 B KREMETART In Giyani Township with the following: Postal Address: P.0 BOX 6349 IVAN 0826 ‘Street Name: N/A Dated: 15/12/2022 Your co-operation will be highly appreciated MUNICIPAL MANAGER OFFICE STAMP IER GIVANI MUNICIPALITY REVENUE MAclee 15 |E BAG X9559 GIVAN! 0826) 4830196244 Visi: Mia are sme iay ton pec Powered by ( CamScanner(nef he Gab! One eey manage pect arnt Payment Notification @ capitec Pease te ee th MUNANAO made payor ci Poymer swrameea eas ert mane LUngoo cate ot ing equ poment Powered by @ camscanner