ACADEMY OF EXCELLENCE Diploma Occupational Health ?· ACADEMY OF EXCELLENCE Diploma Occupational Health…

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  • 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

    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

    mailto:training@ocsa.co.za

  • 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

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