CODE Eduloan Bursary Self payment APPLICATION FOR ADMISSION TO THE TWO (2) YEAR ACT PROGRAMME STARTING IN: 2016 PLEASE ENCLOSE THE FOLLOWING WITH YOUR APPLICATION FORM Certified copy of your identity document / passport Certified copy of highest school qualification Certified copy of ALL your academic qualifications and results of incomplete qualifications Recent payslip (not older than 3 months Eduloan) Letter from principal to provide proof that you teach specific subject/phase or have access to a classroom for duration of programme STUDENT CARD INFORMATION I am already in possession of a STUDENT CARD of the University of the Free State YES NO If you answered YES please indicate UFS student number in the opposite blocks If you answered no please paste 1 passport photo in the appropriate space Complete the following as well: Title: Initials: Surname: Photo If you do not provide a photo, the UFS can not issue a student card National ID / Passport number: SEND COMPLETED APPLICATION TO EDUTEL P O BOX 7632 WESTGATE 1734
APPLICATION FOR ADMISSION TO THE UFS STUDENT NR: Language Preference: English: Afrikaans: Study material will be issued in the language indicated where available Disability: Yes / No If yes please specify: PERSONAL INFORMATION OF STUDENT: Surname: First Names(s): Gender: Male Female Citizenship: SA Other Specify: Population Group: Asian Black Coloured White Title (Mr/Mrs/Ms) Date of Birth: Y Y Y Y M M D D ID / Passport Number: Home Language: Marital Status: Single Married Widow/Widower Divorced Specify church denomination: (to complete this field is not compulsory) Contact Details: Home Tel.: Work Tel.: Fax: ( C O D E ) ( C O D E ) ( C O D E ) E-mail: Cell phone no. you wish to be contacted on: Postal Address: (Where your mail are delivered not school address) Postal Code Home Address: Postal Code Work Address: Please indicate name of school if applicable Postal Code 2
SCHOLASTIC QUALIFICATIONS (Mark with an X): I declare that I have Gr. 12 (Matric) YES NO If yes, state year of completion ACADEMIC QUALIFICATIONS (Study record at higher educational institution [s] attach certified copies of qualifications) From: To: Institution: Degree/Diploma/Certificate Completed/Not completed Example: 1982 1984 Example: UNISA Example: Diploma in Education E.g.: Not completed CENTRE (Please indicate where you want to attend your classes MARK WITH X) Important: Should there not be sufficient students enrolled for your choice of specialization, you may be directed to another centre for your contact classes Bloemfontein Mafikeng QwaQwa Burgersfort Mbombela (Nelspruit) Rustenburg Durban Middelburg Thohoyandou East London Mthatha Ulundi Ermelo Newcastle Vryburg Groblersdal Polokwane Vryheid Katlehong Portshepstone Welkom Kimberley Pretoria Kokstad Queenstown CHOOSE YOUR SPECIALISATION (Please indicate your choice of specialisation MARK WITH X) PLEASE NOTE THAT A MINIMUM OF AT LEAST 10 [TEN] REGISTERED STUDENTS REQUIRED IS FOR A SPECIALISATION TO BE OFFERED AT A CENTRE SPECIALISATIONS NOW AVAILABLE: If you did not pass your selected specialisation field on NSC level 4 (matric 50%), a certified letter from principal stating your teaching experience of at least 2 years in this field of study must be submitted with your application SPECIALISATIONS 1 ST CHOICE 2 ND When can I start with CHOICE my classes? Foundation Phase April, July or October Intermediate Phase (English First Additional Language AND ONE OF: (1)Life Skills /(2) Mathematics / (3)Social Sciences / April, July or October (4)Technology & (5)Natural Sciences {Please circle ONE (1) of these 5 (five) choices} Social Sciences (Snr Phase) April, July or October Life Orientation (Snr Phase) April, July or October English First Additional Language (Snr Phase) April, July or October Economic & Management Sciences (Snr Phase) April, July or October Natural Sciences (Snr Phase) Only April Mathematics (Snr Phase) Only April Mathematics (FET) Only April Mathematics Literacy (FET) Only April Life Sciences (FET) Only April Physical Sciences (FET) Only April THESE SPECIALISATIONS WILL BE IMPLEMENTED SOON SPECIALISATIONS Accounting (FET) English First Additional Language (FET) If you did not pass your selected specialisation field on NSC level 4 (matric 50%), a certified letter from principal stating your teaching experience of at least 2 years in this field of study must be submitted with your application 3
I hereby declare (a) (b) (c) that the above information is true and correct; that I have satisfied myself as to the contents of the Rules and Regulations of the University; that for the duration of my years of study I commit myself to complying with all Rules and Regulations laid down by the University Council or by any other authorised body or person, as well as further Rules and Regulations the University Council or any other authorised body or person may promulgate from time to time, which Rules and Regulations shall form part of my agreement with the University; (d) that I accept responsibility for the prompt payment of all accounts as prescribed in the Rules and Regulations and any other amounts of which I am indebted to the University; (e) (f) (g) (h) (i) (j) (k) (l) that I furthermore undertake to pay all legal costs of the University, including attorney and client costs as well as collecting charges, if I should fail to meet any obligations with regard to payments; that the agreement arising from the signing of this application shall notwithstanding the place of signature deemed to be concluded at Bloemfontein. I the undersigned hereby acknowledge that my registration and participation in the degree/diploma is voluntary, which participation may (depending on the degree/diploma for which I register), without derogating from the generality of the foregoing include, but not limited to, research, practical evaluations, laboratory experiments, exposure to chemicals, germs, unsterilized needles, syringes and other medical equipment, travelling on and off campus, participating in tours and travelling during the course of tours (the related activities ). I furthermore acknowledge that I am aware that there are known and unknown risks and dangers inherent to my participation in the degree/diploma and the related activities, including without limitation, exposure to hazardous substances, air pollution, fire, explosions, micro-organisms, diseases and infections. I understand that these risks may result in potential loss or damage to my property or the property in my possession or under my control and/or my personal injury or death; resulting not only from my own actions, omissions or negligence, but also from the actions, omissions or negligence of others or from the condition of buildings or facilities and/or defective equipment, products or substances. I, the undersigned, hereby waive any and all rights, claims, demands and causes of action which I may have against the University, its employees, contractors and agents arising from my participation in the degree/diploma or the related activities, including without limitation, any claim for damages to my property or property in my possession or under my control, and/or damages resulting from my personal injury or death. I accordingly hereby indemnify the University, its employees, contractors and agents against any and all liability, loss, damages and legal costs which the University, its employees, contractors and agents may incur or sustain as a result of any claims, demands or causes of action which any person (including without limitation, if applicable, my spouse, children or dependants) may have or purport to have to the extent that the same have arisen from, have occurred during or are in any way related to my participation in the degree/diploma or the related activities. I undertake to familiarise myself with all rules and regulations of the University and/or any specific rules laid down by any department of the University, which may include, but will not be limited to rules regarding off-campus travelling, laboratory rules or any safety rules as well as any specific instructions and/or arrangements given by any department of the University. I furthermore agree to obey all the said rules, regulations and/or instructions. I acknowledge that I have read this document, understand its contents and agree to its terms and conditions. I further acknowledge that I am signing this agreement freely and voluntarily. Signature of student:... Date:. Sign here IMPORTANT All Rules and Regulations of the University are available on request at the Administration, and are also open to inspection at the UFS Sasol-Library and the UFS Website at http://www.ufs.ac.za Eduloan: Please contact me for finance for a laptop: (Only if you ve completed an Eduloan application form) YES NO 4
APPLICATION FOR THE TWO (2) YEAR ACT REGISTRATION: STARTING IN 2016 Please note that registration will only take place if: 1. Your application has been approved 2. The minimum fee for registration has been paid I, (First names and surname), Student nr. grant the University of the Free State permission to register me for the following: Qualification: ACT Specialisation: Centre: Year: 2 0 1 6 OFFICIAL USE ONLY: PROGRAMME NUMBER PLAN NUMBER ADMISSION TERM CENTRE APPROVED BY (Print name) MODULES: 1 ST YEAR 2 ND YEAR MODULE CENTRE MODULE CENTRE If, however, there are not enough students for my first choice of specialisation, I grant permission to the University of the Free State to register me for my second choice. Signed at, on (date). Signature: STUDENT Sign here 5
WORKPLACE CONFIRMATION LETTER To whom it may concern I hereby confirm that Mr/Ms/Mrs, Identity/passport number: is teaching or has access to a classroom to teach the specific subject and phase (as indicated below) for the duration of the two (2) year programme enrolled for: Phase enrolled for: Name of school: School address: Postal code: Signed: Date: Position held: Persal number: Contact number: School/Circuit/District stamp. Officl Stamp Official Stamp 6