2014
APPLICATION FORM FOR ENROLMENT INTO SHORT COURSE:
Title of Course: ……………………………………………………………
OFFICE USE
Start dates of Course: ….…………………. Course Code:…………
FULL FIRST NAME & SURNAME: ……………………………………………………….
(AS IT APPEARS ON YOUR I.D. / PASSPORT)
PASSPORT / IDENTITY NUMBER:………………………………………………………
DATE OF BIRTH: …………………..…………… GENDER:……………………………
POSTAL ADDRESS / PHYSICAL ADDRESS:
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E MAIL ADDRESS(ES): …………………………………………………………………….
TELEPHONE NUMBER(S): …………………………….................................................
FAX NUMBER: ………………………… MOBILE NUMBER: …………………………..
QUALIFICATIONS: (List maximum 3)
Degree / diploma / certificate
Institution
Date obtained
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CURRENT OCCUPATION:
JOB TITLE: ………………………………………….. WHEN STARTED: ………………
Community Eye Health Institute, Division of Ophthalmology, Faculty of Health Sciences, University of Cape Town
Private Bag 3, RONDEBOSCH 7700, Republic of South Africa
Tel (+27)21-406 6215/6 fax (+27)21-406 6218
www.cehi.uct.ac.za
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NAME AND TITLE OF LINE MANAGER: ………………………………………………….
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Give a brief description of the work that you do:
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How much (%) of your daily work load is directly related to:
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Working with patients having eye problems
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Planning and organising eye services
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Providing administrative support for eye programmes ……………………………………………..
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Managing staff and resources of an eye programme …………..…………………………………..
Tell us why you are interested in participating in this course and how you may benefit from it:
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FUNDING STATEMENT: My fees for the course…………………………………………………………….
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If accepted, I undertake to:
1. Participate fully in the course so as to obtain the most benefit from the learning process;
2. Complete all tasks assigned to me with diligence in the format and by the due date required;
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Applicant (Signature)
Date
Community Eye Health Institute, Division of Ophthalmology, Faculty of Health Sciences, University of Cape Town
Private Bag 3, RONDEBOSCH 7700, Republic of South Africa
Tel (+27)21-406 6215/6 fax (+27)21-406 6218
www.cehi.uct.ac.za
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DECLARATION OF EMPLOYER / SPONSOR
I, ……………………………………………………………………….………………………………(Name)
…………………………………………………………………………………………..………(Designation)
…………………………………………………………………………………………….……(Organisation)
confirm that we undertake to pay the course fee of R……………… ………………………on behalf of
………………………………………………………………………………………………(name of student)
And will further support the student as follows:
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Payment of travel expenses
Payment of accommodation expenses for the duration of the course
Payment of pocket money for the duration of the course
(Delete if not applicable).
I further confirm that: (explain in which way your organisation will be able to support the student after
completion of the course, in order to facilitate implementation of the new learnings):
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NAME (EMPLOYER OR SPONSOR)
DATE
Community Eye Health Institute, Division of Ophthalmology, Faculty of Health Sciences, University of Cape Town
Private Bag 3, RONDEBOSCH 7700, Republic of South Africa
Tel (+27)21-406 6215/6 fax (+27)21-406 6218
www.cehi.uct.ac.za
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