GRADUATE REGISTRATION FORM LEEPA CGDM

“Changing lives to build tomorrow’s workforce”

Note: All information contained herein will be handled with strictest confidence and is for the purpose of our records only.
A registration fee of R350.00 is non-refundable.

SURNAME

FIRST NAMES

DATE OF BIRTH INITIALS

D D M M Y E A R
ID NUMBER

CELLPHONE NUMBER HOME TELEPHONE NUMBER

- -
ALTERNATIVE CONTACT NUMBER FAX
- -
EMAIL

NATIONALITY

PASSPORT NUMBER (if you are not a South African citizen)

HOME PROVINCE

PROVINCE CURRENTLY RESIDING

TOWN

HOME ADDRESS

POSTAL ADDRESS POSTAL CODE

RACE

DISABILITY

DRIVER’S LICENCE
(code)

QUALIFICATIONS

 HONOURS ⃝ (please tick) ● CERTIFICATE ⃝ (please tick)

 MASTERS ⃝ (please tick) ● LEARNERSHIP ⃝ (please tick)
 DEGREE ⃝ (please tick) ● INTERNSHIP ⃝ (please tick)
 DIPLOMA ⃝ (please tick) ● OTHER ⃝ (please tick)

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 GRADUATE REGISTRATION FORM LEEPA CGDM

LEARNERSHIP/INTERNSHIP (only fill in if you completed the programs.)

N A M E O F O R G A N I S A T I O N
TITLE

DURATION OF THE PROGRAM

YEAR OBTAINED
Y E A R

EMPLOYMENT STATUS

PERMANETLY EMPLOYED ⃝ (please tick) SELF-EMPLOYED ⃝ (please tick)

TEMPORARILY EMPLOYED ⃝ (please tick) STILL STUDYING ⃝ (please tick)
UNEMPLOYED ⃝ (please tick) OTHER ⃝ (please tick)
NAME OF INSTIITUTION
N A M E O F I N S T I T U T I O N
POSITION HELD

START DATE CURRENT WORK ⃝ (please tick)

D D M M Y E A R
END DATE YEARS OF EXPERIENCE : ___year
D D M M Y E A R

PLEASE ATTACH THE FOLLOWING:

 RECENT CURRICULUM VITAE.

 CERTIFIED IDENTITY DOCUMENT (not later than 3 months).
 CERTIFIED COPIES OF YOUR QUALIFICATIONS (not later than 3 months).
 PROOF OF PAYMENT

Banking Details

Account Holder: Leepa Graduate Development.

Account: FNB account
Account No: 62737655558
Branch Code: 250 655
Reference: Use your name and surname

Declaration:

I declare that all the information provided (including any attachments) is complete and correct to the
best of my knowledge. I understand that any false information supplied could lead to my application
being disqualified.

SIGNED DATE:
D D M M Y E A R

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