Registration for Student support services | Liedani cc t/a Synergetica Student Support Centre

Personal Information:

Title: *

First names as per ID/Passport: *

Surname: *

Gender: *

Language (All study materials are provided in English): *

Identity Number: *

Email: *

Employer:

Position: *

Highest Qualification (ie. Grade 12 / BA degree): *

Course you want to receive student support for: *

Telephone Numbers:

Home:

Work:

Cell: *

Fax:

Address:

Residential Address: *

Postal Address: *

Town: *

Province: *

Town: *

Province: *

Relevant Documents:

Certified copy of ID / Passport *

Proof of residence *

Curriculum Vitae *

Testimonials

Qualifications

Please attach certified copies with each qualification.

Qualifications

Year From

Year To

University / Institution

Certified Document

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By submitting this registration form I confirm that the information supplied by me is correct and true. I undertake to pay the prescribed fees and take note that the fees are NON-REFUNDABLE.

The invoice will be sent upon submitting this registration form.

Student Support Services

Personal Information:

Telephone Numbers:

Address:

Relevant Documents:

Qualifications