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