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Open Distance Application Form

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Application Form
Open Distance
Learning
Do you want to further your career by means of a degree or diploma at an inter-
nationally recognised university, but cannot do it full time? Is time a problem? If
so, then the Potchefstroom Campus of the North-West University’s Open Distance
Learning Programme is catered specifically for you.
The Open Distance Learning Programme is a unique and creative process where
you determine the place, time and tempo of learning, thus speeding up your ca-
reer through professional training. Electronic and telephonic support is available,
as well as personal contact in the study centres.
Why choose the Open Distance Learning Programme?
• Studywithsupportwhileworking.
• Itisaffordable.
• Thereisanetworkofstudycentres,nationallyandabroad.
• Therearededicatedcallcentres.
• Youreceiveaninternationallyrecognisedqualification.
• Youreceiverecognitionofpriorlearning.
• Youreceivevocationallydirectedtrainingthatspeedsupyourcareer.
• Youdetermineyourtempooflearningbasedonyourcircumstances.
• Adminandfinancialresponsearequickandeasy.
• We have helpful, supportive facilitators with the latest knowledge and
expertise.
• Thisextensivelearningprogrammehasensuredsuccessformanystudents.
Ifyouwerelookingforqualityacademiccontentanddedicatedfacilitators,rest
assured that you have found the perfect training solution at the Potchefstroom
Campus of the North-West University.
INTRODUCTION
The North-West University (NWU) consists of three campuses: The Potchefstroom Campus, Vaal Triangle Campus and Mafikeng
Campus. The Institutional Office are located in Potchefstroom.
The NWU is a value-driven institution that promotes tolerance and respect for all perspectives and belief systems in order to
facilitate an environment conducive to teaching-learning, research and community service. The value system and practices of the
NWU will be driven by the values enshrined in the Constitution, especia
lly human dignity, equality and freedom. This includes the
promotion of unity in diversity.
IMPORTANT
Read the following instructions and information carefully before completing the form. Incomplete information can lead to
unnecessary delays in the processing of your application.
1. This application form should be completed by all students who want to study as part of the ODL programme.
2.
The following documents should accompany this application (only certified copies are accepted):
2.1 Copies of certificates obtained at another tertiary institutions;
2.2 Identity document.
2.3 Matric Certificate
2.4 South African Nursing Council receipt and registration certificate. (only applicable for nursing)
2.5 If employed, attach pay-slip
ALL COPIES SHOULD BE CERTIFIED
NB: If any of the above documents have been issued in the maiden name of the applicant, a certified copy of the marriage
certificate should accompany this application.
3. The University reserves the right to refuse any application without supplying reasons for such a decision.
4. Population Group and Religion - Although this information is vital for statistical purposes, answering is optional.
SELECTION
1. The University reserves the right to require of candidates who have not obtained a specific average pass mark, to write an
additional selection test on the basis of which final consideration will be given to the application of such a candidate.
Following receipt of applications for admission, candidates will be informed as to whether they are expected to write the
selection tests and as to the date, time and venue.
2. Approval of applications further depends on post-school training and education and/or applicable work experience.
UNIVERSITY NUMBER
Please note that the allocation of a university number does not necessarily mean that you have been accepted as a student.
ALL CORRESPONDENCE TO:
POTCHEFSTROOM CAMPUS
The Unit for Open Distance Learning
North-West University (Potchefstroom Campus)
Private Bag X6001
2520 POTCHEFSTROOM, RSA
Unit for Open Distance Learning
Tel: (018) 285 5900
Fax: (018) 299 4558
E-mail: DistancePotch@nwu.ac.za
1
A.1. APPLICATION FORM University number (office use):
During which year do you intend to commence your study at this University?
Open Distance Learning Study Centre e.g. Secunda
Have you been registered at this University before? Yes No
If yes, please supply university number First year of registration (e.g.1994)
A.2. Qualication
Qualification that you wish to enroll for:
A.3. Biographical Particulars of Applicant: Identity number
Surname Initials
Birth date Title e.g. Mr
First names Gender Male Female
Preferred name Maiden name (married woman)
Marital Status Single Married Other (please specify)
Nationality South African Other (please specify)
Population group Asian White Coloured Black Information Confidential
Other (please specify)
Please complete where applicable:
EMPLOYER:
PROFESSION AND POSITION:
Religious affiliation (specify) Information Confidential
Home language Afrikaans English Other (specify)
Preffered language for correspondence Afrikaans English
B. CONTACT DETAILS
Preferred method of communication Post E-mail Fax
Do you have access to CD-ROM facilities? Yes No
Home address
Postal code
2
Qualification e.g. Curriculum code Programme code
(Health Science Education)
2 0
Y Y Y Y M M D D
Postal address (if different from home address)
Postal code
To whom should the account be sent? Applicant personally Mother Guardian Father Other
To which address should the account be sent? Home address Postal address Other
Please specify “other”.
Postal code
To which address should study material be sent? (only ODL students) Home address Postal address
Cell phone number
Home tel. no. Area code Number
Work tel. no. Area code Number Extension
Fax no. Area code Number
E-mail address Internet/facbook address
C. POST-SCHOOL ACTIVITIES
Primary activity in year prior to study at the NWU:
School University Technical Institute Other (specify)
Work University of Technology Teachers’ Training College
Will this be your First Second/further registration at a tertiary institution?
Have you partake in any examination at a tertiary level? Yes No
Complete in reverse order (starting with the most recent) all tertiary academic work, including incomplete qualifications
(compulsory for evaluation purposes)
Period Name of university/
college/university of
technology, etc.
Name of degree/
diploma/certificate
Study completed
University-
Student no.
From
Year/Month
To
Year/Month
Yes No
D. EMPLOYMENT RECORD
Please record your most recent positions of employment, starting with your current position(s):
Period Occupation Employer
From
Year/Month
To
Year/Month
SA Nursing Council Reference Number (Nursing applicants only)
Theology students must attach a certified matric certificate
University number (office use):
3
University number (office use):
E. KINSHIPS
Spouse/family member Surname ID
Initials Birth date Title
Nationality: South African Other (specify)
Occupation Employer
Home address
Postal code
Postal address (if different from home address)
Postal code
Work address
Postal code
E-mail address Cell phone number
Home Tel. no. Area code Number
Work Tel. no. Area code Number Fax. no.
F. UNDERTAKING BY THE STUDENT
(IF STUDENT IS UNDER AGE WE ALSO REQUIRE THE SIGNATURE OF PARENT OR GUARDIAN)
1. The University will at all times be entitled to summarily cancel the student’s registration should it become apparent that the information
supplied in this form is false or incorrect.
2. The student is subject to all the rules and regulations contained in the brochures and the Institutional State of the University, including the
rules and procedures with regard to student discipline
3. The University will take all reasonable steps to prevent the student from being injured or prejudiced by any in injury, loss or damage,
whether or not it is caused by the negligence of the University or any of its employees, or a fellow learner. The student undertakes not
to institute any claims against the University in respect of such injury, loss or damage and further undertakes to indemnify the University
should the University incur any liability whatsoever pursuant to any negligent or other act or omission by the student.
4. The student, his/her dependants, executors, administrators and/or assignees relinquish and indemnify the University against any claim for
injury, loss or damage of whatsoever nature which may arise on or outside the campuses of the University or on or in any other location
or facility contracted by the University in connection with his/her study, during the period of study with the University.
5. By signing this application form and any subsequent registration forms, the student, and if applicable his/her natural or legal guardian
confirms and acknowledges that the above provisions form part of the student’s study contract with the University and is binding on the
student, his/her aforesaid guardian, and their dependants, executors, administrators and assignees.
6. Potchefstroom shall be regarded as the place where this agreement has come into existence, irrespective of where it may have been
signed.
7. I, the undersigned, will be responsible for the prompt payment of all and any money payable to the NWU in terms of my enrollment and/
or association with the NWU, now and in future, as set out in more detail in the official University brochures as determined and amended
by the University Council from time to time. The contents of these brochures form the basis of the financial agreement between the
University and myself and are regarded to be incorporated in their entirety into this agreement. I shall forthwith fax proof of every deposit/
payment made with regard to monies paid into the University’s bank account to enable the University to credit the student’s personal
study account with the University.
8. If I/the student fail/fails to make payments on pre-determined due dates, and if the University, at the University’s sole discretion should
hand over to attorneys any amount of monies for collection, I undertake to pay all costs whatsoever which may be due and payable,
including tracing fees, collection charges, advocate’s fees, and any expenses of whatever nature on an attorney-and-own-client scale. Any
fees payable by me/ the student will firstly be allocated to the aforementioned costs, thereafter to interest and only then to the capital
amount. A wage attachment order(s) may also immediately be issued against my/our employer(s) in order to attach my/our salary/salaries
or wage(s) in order to collect the outstanding amount as a whole or in instalments.
9. Any amount owing and payable to the University in terms of the University’s financial rules as published in the brochure entitled “Fees
Payable and Financial Rules”, may be fixed and proven by means of a certificate issued and signed by an authorised official of the
Y Y Y Y M M D D
4
55
University. Such a certificate shall be binding and will serve as prima facie proof of the extent and existence of such amount, unless and
until the contrary is proved.
10. I hereby bind myself jointly and severally and in solidum together with the student to properly meet all conditions contained herein.
11. These conditions will remain valid and in force for the full duration of my/the student’s enrollment as a student at the University and
thereafter until all commitments in terms hereof have been met.
12. I have satisfied myself as to and subject myself to all the rules and regulations contained in the brochures and in the Institutional Statute
of the University which form part of this agreement and/or as it may be amended from time to time.
13. Do you currently own any amount of money to any tertiary institution in South Africa? Yes No
14. If the answer in above is YES, please indicate the name of the Institution and the amount that is owed and attach all relevant details.
Name of Institution: Amount owed:
Signed on this day of
SIGNATURE OF STUDENT SIGNATURE OF WITNESS / PERSON LIABLE FOR PAYMENT
NAME AND SURNAME (please print) NAME AND SURNAME (please print)
ID number ID number
G. SURETY SHIP (IF NOT FULL TIME EMPLOYED, IF FULL TIME EMPLOYED, ATTACH CERTIFIED PAY-
SLIP)
1. I, the undersigned,
Full names and surname
Identity number
hereby bind myself as surety and co-principal debtor in solidum (i.e.,for the full amount) for the due performance by the
student of all his/her financial obligations towards the University as set out in paragraph 3 of section J above.
I confirm that I understand the meaning of the term in solidum as explained in the paragraph above
2. I hereby renounce the benefits arising from the legal exceptions de duobus vel pluribus res debendi and ordinis seu
excussionis, and I confirm that I am aware of the legal effect of the above-mentioned renunciation, namely that it entails
the following:
2.1 duobus vel pluribus res debendi (the principle that a debtor is only liable for a portion of the amount payable): The
University can, in its discretion, claim full payment of all outstanding monies owing to it from either the student or
from myself as surety or jointly from both of us.
2.2 ordinis seu excussionis (the principle that a debtor is regarded as secondary and becomes liable only after the portion
owed by the main debtor had been collected): I shall not be entitled to force the University to proceed against the
student as principal debtor and to excuss him/her first before claiming performance from me as surety.
Signature Date
Signature witness ID number
University number (office use):
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Y Y Y Y M M D D
University number:
H. OFFICE USE ONLY
H.1. RECOMMENDATION BY FACULTY/SELECTION COMMITTEE
Application approved Application rejected Year level to which admitted
Other recommendations __________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________
ADMINISTRATIVE MANAGER/CHAIRPERSON: ________________________________________ DATE
H.2 RECOMMENDATION BY THE SCHOOL DIRECTOR
NOTE: ONly applicablE TO pOsTgraduaTE applicaTiONs, ExcludiNg MasTErs/dOcTOrs dEgrEE sTudENTs
Application approved Application rejected
Other recommendations __________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________
SCHOOL DIRECTOR: __________________________________________________________ DATE
FOR OFFICE USE ONLY TB P
YEAR: 20..........
University number: ___________________________________________________ Qualification: ______________________________
Title: ______________ Initials: _______________ Surname: ____________________________________________________________
Journal entry Bursary
Tuition fee: R T K P J B
First payment: R T K P J B
Age exemption/Postgraduate R T K P J B
TOTAL
Receipt number: ______________________ Date: _________________________ Signature: _____________________________
AMOUNT RECEIVED
FIRST PAYMENT
6
Y Y Y Y M M D D
Date application is processed:
Signature: ____________________________________________
Y Y Y Y M M D D
According to the 2010 figures of the Department of Higher Education and
Training(publishedin2012),theNWUratedverywell,benchmarkedagainstthe
other22highereducationinstitutionsinSouthAfrica.Hereistheevidence:
• In2010theNWUwasthethirdlargestuniversityinSouthAfricabasedon
thetotalheadcount,namely55732(in2009itwas50589,whichisan
increaseof10,2%).Intermsofdistancestudents,theNWUwasthesecond
largestinSA.
• Forthe total number of degrees and diplomas awarded in 2010, namely
15083,theNWUratedsecondinthesector(2009:13445,anincreaseof
12,2%).
Teaching-learningscoreboardfor2011:
• TheNWU’sundergraduatepassratefor2011was85,2%forcontactstu-
dentsand85,3%fordistancestudents,puttingtheNWUwellaheadofthe
national average.
• Withregardtothegraduationrateof26,6%forcontactstudentsand29,9%
for distance students, the NWU once again finds itself in the top echelon of
the country’s universities.
a LEADING
university
The vision of the NWU is to be a “pre-eminent
university in Africa, driven by the pursuit of knowledge
and innovation”
Vision of the NWU
To become a research-directed campus where
teaching-learning and research are mutually
reinforcing.
Mission of the
Potchefstroom Campus
WORK INTEGRATED LEARNING (WIL UODL) PR 02
REGISTRATION: WIL DATABASE
This must be completed in full.
Attach this form to your application forms.
All fields are compulsory, except where email addresses are not available.
Please note that our preferred method of contact is through e-mail.
STUDENT INFORMATION:
NWU STUDENT
NUMBER*
OLG STUDENT
NUMBER*
*Office use only
Please complete in full and write clearly and neatly in block letters
ID NUMBER
CONTACT CENTRE NEAR
YOU:
PRIVATE OR
PROVIDE NAME OF BURSARY
TITLE
INITIALS
FULL NAME
PREFERRED NAME
SURNAME
CELLPHONE NUMBER
EMAIL ADDRESS
PREFERRED LANGUAGE
HOMETOWN
PROGRAMME/QUALIFICATION
GR R
BEd FP
BEd
Int/Snr
PGCE
ACT
CURRENT EMPLOYER
Are you currently in a teaching position?
Yes
No
If yes, please indicate Grade (s) you are
responsible for
Number of years in a teaching position
Years
Months
NB: All fields are compulsory and must be completed
Signature of student: ________________________
SCHOOL INFORMATION:
(Completed by the School that will be hosting the student for WIL)
The Primary and/or Pre -Primary School must have a Grade R classroom .
Please complete in full.
FULL OFFICIAL NAME OF
SCHOOL
QUINTILE SCHOOL
1 OR 2 OR 3 OR 4 OR 5
EMIS NUMBER
TELEPHONE NUMBER
FAX NUMBER
EMAIL ADDRESS
GRADES (e.g. R – 7)
LANGUAGE MEDIUM
POSTAL ADDRESS
POSTAL CODE
STREET ADDRESS
POSTAL CODE
AREA / RESIDENTIAL AREA
TOWN
PRINCIPAL
TITLE
INITIALS
SURNAME
PREFERRED NAME
TELEPHONE NUMBER
E-MAIL ADDRESS
SCHOOL MENTOR INFORMATION:
Post level requirements for appointment of Mentor for student at the school (one of the following):
Principal
Deputy Principal
Qualified Grade 1 Teacher with five (5) years or more relevant teaching experience
Qualified Grade R Teacher with five (5) years or more relevant teaching experience
Foundation Phase HOD.
Senior Phase HOD
Qualified educator in the phase that is relevant to student.
TITLE
INITIALS
SURNAME
PREFERRED NAME
POSITION HELD (e.g. Principal)
NUMBER OF YEARS OF
TEACHING EXPERIENCE
YEARS
MONTHS
TELEPHONE NUMBER
E-MAIL ADDRESS
Student will be able and allowed to complete WIL as per the
requirements for the WIL.
Yes
No
Signature of mentor: __________________
PRINCIPAL:
I hereby confirm that the student will be able and allowed to complete WIL at this
school.
Signature: Principal Date
Original details: 11080655 C:\Users\11080655\Desktop\11080655\Documents\WIL\Forms\ 2015/11 May 2015 File reference: IL PR02
Form
SCHOOLSTAMP
(Compulsory)
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Open Distance Application Form

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Completed 1 February 2021

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