ACADEMY OF EXCELLENCE Diploma Occupational Health Nursing

Property of Occupational Care South Africa (Pty) Ltd. © Page 1 of 2 OCSA document number AE OHD Application for Diploma in Occupational Health Nursing 2016 ver 1 2.doc August 2015

APPLICATION FORM

COURSE DIPLOMA IN OCCUPATIONAL HEALTH NURSING

YEAR OF STUDY 2016

VENUE OCSA Academy of Excellence, Alberton, Gauteng Tel: 011 864 1173

INSTRUCTIONS

Before an application will be considered, the following documentation must be submitted.

1. This form must be completed in clear print together with all required documentation.

2. Proof of payment of the non-refundable application fee of R500.00.

Banking details: FNB Northcliff, Branch: 253-705, Account no: 50400065261, Ref no: Dip2016<Surname>

Send it to: training@ocsa.co.za Incomplete applications will not be considered.

3. Closing date for applications is 30 November 2015.

A confirmation letter will be send to your e-mail address on receipt of your application.

If you have not received confirmation within 2 weeks, please enquire with us or re-send your application.

CANDIDATE DETAILS

Given Names Surname

Title Maiden Surname

Identity No SANC Number

Passport Number Country of issue

Highest Qualification Gender Male Female

Work Tel Cell

Email Signature

Postal Address

Physical / Residential Address

Please complete all the fields – incorrect or incomplete forms will not be considered as an application.

Province in which you live

Eastern Cape Mpumalanga

Free State Northern Cape

Gauteng North West

KwaZulu Natal Western Cape

Limpopo Other country

Employment Equity

Code

Black African Indian / Asian

Coloured Person White

Nationality

South Africa Mozambique

Angola Namibia

Botswana Swaziland

Lesotho Zimbabwe

Malawi Other - Name

Home Language

(Predominant used home language)

Afrikaans Sesotho

English Setswana

isiNdebele siSwati

isiXhosa South African Sign Language

isiZulu Tshivenda

Sepedi Xisonga

Other Please specify

Resident Status SA Citizen SA Permanent Resident

ACADEMY OF EXCELLENCE Diploma Occupational Health Nursing

Property of Occupational Care South Africa (Pty) Ltd. © Page 2 of 2 OCSA document number AE OHD Application for Diploma in Occupational Health Nursing 2016 ver 1 2.doc August 2015

Dual (SA + other) Other

Specify what other Specify what other

Socioeconomic Status

Employed – no study leave

Employed – on study leave

Working part-time / locum

Not working

Disability Status

None

Sight Experience problems even when wearing glasses / contact lenses

Hearing Experience problems even when wearing hearing aid or with implant

Communication Talking / Listening

Physical Moving / standing / grasping

Intellectual Difficulties in learning / retardation

Emotional Behavioural or psychological

Other Not mentioned above

REQUIRED DOCUMENTS

Current SANC receipt Proof of SA indemnity / Prof insurance

Copy of diploma/degree in Nursing Copy of ID

Motivation to attend this course, in less than 700 words CV – specific study & work history

Foreign student – SANC approval Foreign student / Proof of Qualifications

PAYMENT DETAILS

Person responsible for payment Tel

Relationship to student e-mail

DECLARATION BY LEARNER

Answer these three questions with a definite “YES” or “NO” by making a cross (X) 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 professional conduct action being taken against you.

1. Are you now, or have you previously been, registered or enrolled with the South African Nursing Council as a Nurse / Midwife / Nursing Auxiliary?

YES NO

2. Have you ever been found guilty of an offence in any country? YES NO

3. Is a charge of an offence pending against you in any country YES NO

I certify that the information on this application form is true and correct. YES NO

Signature of applicant Date Total amount paid R

FOR OFFICE USE

Certified copies of the following documents have been received:

Copy of ID SANC Receipt

Proof of Indemnity CV

Diploma / Degree in Nursing Motivation letter

Proof of Application fee payment Verified by

Date Confirmation sent

Approved YES / NO 1 Year 2 Years

Notes