APPLICATION FOR REGISTRATION: STUDENT MEDICAL TECHNICIANS/ LABOTORY ASSISTANT Form 53 GTS/ LAS

APPLICATION FOR REGISTRATION:
STUDENT MEDICAL TECHNICIANS/ LABOTORY
ASSISTANT
Form 53 GTS/ LAS
NB: AN INCOMPLETE FORM WILL DELAY REGISTRATION
Please PRINT and return the ORIGINAL FORM to:
The Registrar, PO Box 205, Pretoria 0001
553 Vermeulen Street, Arcadia, Pretoria 0083
A.
FOR
OFFICE
USE ONLY
PERSONAL PARTICULARS
I, (Mr, Mrs, Miss)
Received on
Surname:
……………………………………..
Amount
Maiden name (if applicable):
……………………………………..
First names:
Identity No.:
Receipt No.
Postal address:
……………………………………..
Postal code:
No.
……………………………………..
Residential address:
Reg. Date
Postal code:
……………………………………..
Tel (H):
(W):
Cell:
Fax:
VERIFIED
……………………………………..
Email:
DATE
* Marital Status:
* Race:
Divorced
Asian
Married
African
Single
Coloured
hereby apply to register as a Medical
Technician/
Laboratory
Assistant
Student in the following:
White
Gender:
Male
Female
…………………………………….
CAPTURED
Country of origin:
……………………………………..
DATE
*Register:…………………………………………………………
*Category: …………………………………………………………
……………………………………..
VERIFIED
……………………………………..
DATE
SIGNATURE:
B.
C.
Date:
20
…………………………………….
The following is submitted in support of my application:
1.
Current registration fee of R156.00. Please attach the proof of payment.
2.
A copy of my identity document or birth certificate.
3.
A copy of my marriage certificate (should you wish to register in your married surname).
4.
An additional fee of R71.00 in respect of each month or part of a month which my application is
submitted later than four months after date of registration at the Training Educational Institution.
TO BE COMPLETED BY THE TRAINING INSTITUTION
Certificate of having commenced study as a student, issued by:
(name of Laboratory
indicating that he/she enrolled on
in the (first, second, etc.)
(day)
(month)
(year)
year of study.
ORIGINAL OFFICIAL DATE STAMP OF
THE LABORATORY
SIGNATURE: Laboratory Manager
DATE
* Please complete for statistical purposes.
NB: Please note that the Council, in the normal course of its duties, reserves the right to divulge information in
your personal file to other parties.
SN/06-2014