GENERAL INFORMATION AND INSTRUCTIONS
This form must be completed in full. Incomplete application forms will not be processed.
Certified Copies of the following documents must be submitted together with your application.
• An Identification Document
• National Senior Certificate (Grade 12) or equivalent qualification. An applicant may apply with Grade
12 June results.
• Applicants who wish to complete their studies with Glen Agricultural College must submit official proof
that they have complied with all the requirements for a Diploma in Agriculture.
• Admission criteria – Mathematics, Mathematics Literacy (60% or above pass rate) Physical Science,
Accounting, Agriculture and Biology are compulsory subjects for admission at Glen Agricultural College
Admission is subject to the condition that an applicant complies with the admission criteria.
No cash will be accepted with the applications received by post or delivered personally.
NON-REFUNDABLE APPLICATION FEE
An application fee of R150.00 is payable for application to study.
Method of Payment:
Direct Deposit into the following account:
Bank: First National Bank
Account Name: Studente Unie Glen Landboukollege
Account number: 51713258379
Please provide your identity or passport number as reference on the deposit slip when paying at the bank
or via internet.
The Registrar
Glen Agricultural College
Private Bag x01
Glen
9360
Telephone:
051 861 8316 /
051 861 8314
Closing date:31 October 2015
Application for Admission / Aansoek om Toelating YEAR
STUDENT NUMBER(IF PREVIOUSLY REGISTERED
INDIEN VOORHEEN
STUDENTENOMMERGEREGISTREER)
PLACE ID PHOTO
HERE
RECEIPT NUMBER(OFFICE USE ONLY
SLEGS VIR
KWITANSIENOMMERKANTOORGEBRUIK)
1. DETAILS OF APPLICANT
(Complete in block letters and in black ink / Voltooi in drukskrif en in swart ink)
BESONDERHEDE VAN AANSOEKER
Title:ID number if South African:
Ti[Link] indien Suid-Afrikaner:
First names:
Voorname:
Surname:
Van:
D D M M Y Y Y Y
Gender: Male/Manlik Date of Birth:
Geslag: Female/Vroulik Geboortedatum: - -
D D M M J J J J
Marital Status: Single/Ongetroud Married/Getroud Divorced
Huwelikstatus:
ETHNICITY/ETNISITEIT:
African: Asian: Coloured: White: Other:
Swart:Asiaat:Kleurling:Wit:Ander:
2.1 DETAILS OF APPLICANT / BESONDERHEDE VAN AANSOEKER
Telephone numbers:(Home)/(Huis) EXAMPLE:
051000 9900
VOORBEELD: 051000 9900
Telefoonnommers:
(Work)/(Werk)
Cellphone number:NB: SMS messages will be sent to this number
: SMS-boodskappe sal na hierdie nommer
Selfoonnommer: gestuur word
Email address: E-
posadres:
NB: Acknowledgement
of receipt and other communication will be sent to the above email address. : Ontvangserkenning
en ander kommunikasie sal na bogenoemde e-posadres gestuur word.
Residential address:
(No postal address must be indicated
here)
Woonadres:
(Geen
posadres moet hier aangeduiPostal code:
word nie)Poskode:
Postal address: (if different from
residential address) Posadres: (indien
verskil van woonadres)
Postal code:
Poskode: Prefer communication via:
Verkies kommunikasie deur: Email/E-pos Post/Pos
2.2 LANGUAGES (Mark with an X where applicable)
TALE (Merk met 'n X waar van toepassing)
Home language: Afrikaans Setswana isiNdebele
Huistaal: Tswana Ndebele Xitsonga Tsonga
English siSwati Sesotho sa
Sesotho
Engels Swati Leboa
Suid-Sotho
Noord-Sotho
isiZulu Zulu isiXhosa Xhosa Tshivenda Other
Venda Ander
3. DETAILS OF PARENT/GUARDIAN/OTHER RESPONSIBLE PERSON SUCH AS NEXT OF KIN (IN CASE OF AN
EMERGENCY):
KONTAKBESONDERHEDE VAN OUER/VOOG/ANDER VERANTWOORDELIKE PERSOON SOOS NAASBESTAANDE
(IN GEVAL VAN NOOD):
Surname:Initials:
Van:Voorletters:
Relationship:Title:
Verwantskap:Titel:
ID number:
ID-nommer: (Home/Huis) EXAMPLE: 0510009900
Telephone numbers:VOORBEELD: 0510009900
Telefoonnommers:(Work/Werk)
Cellphone number:
Selfoonnommer:
Email address: E- posadres:
Residential address:
(No postal address must
be indicated here)
Woonadres:
(Geen
posadres
moet hier
aangeduiPostal code: word nie)
Poskode:
Postal address: (if different from
residential address) (Where mail must
be delivered)
Posadres: (indien verskil van
woonadres)Postal code:
(Waar pos afgelewer moet
word)Poskode:
4. SCHOOL SUBJECTS (for languages, please state whether 1st, 2nd or 3rd language) / Current Grade 12 learner
SKOOLVAKKE (by tale, dui asb aan 1ste, 2de of 3de taal) / Huidige graad 12-leerder
5. IF YOU WERE REGISTERED AT ANY OTHER UNIVERSITY / TERTIARY INSTITUTION IN THE PAST,
PLEASE SUPPLY THE FOLLOWING INFORMATION:
INDIEN U VOORHEEN BY ENIGE ANDER UNIVERSITEIT / TERSIÊRE INSTELLING GEREGISTREER WAS,
VERSKAF ASSEBLIEF DIE VOLGENDE INLIGTING:
UNDERGRADUATE ONLY / SLEGS VOORGRAADS
16. IN NO MORE THAN 200 WORDS, PLEASE TELL US MORE ABOUT YOURSELF. YOU COULD MENTION YOUR FAMILY, YOUR SCHOOL, YOUR EXPERIENCES GROWING
UP, YOUR SKILLS (WHAT YOU ARE GOOD AT), YOUR IN NOT MORE THAN 300 WORDS, TELL US WHY DO YOU WANT TO
STUDY AGRICULTURE AT
INTERESTS AND HOBBIES AND YOUR PERSONAL QUALITIES.
VERTEL ONS VAN USELF IN NIE MEER AS 200 WOORDE. U SAL MISKIEN DIE VOLGENDE WIL NOEM: U
GESIN, U SKOOL, U GROOTWORD-ONDERVINDINGE, U TALENTE (DIT WAARIN U GOED IS), U BELANGSTELLINGS
THE GLEN AGRICULTURE
COLLEGE.
EN STOKPERDJIES EN U PERSOONLIKE EIENSKAPPE.
AUTHORISATION FOR MEDICAL SURGERY (MEDICAL OPERATIONS)
Should the circumstances be such that it is impossible to gain permission beforehand, I hereby grant
authority to the Head of Glen Agricultural College or their assignee, in case it should, in an emergency be
necessary to perform an operation on my son/daughter/foster-son/foster-daughter to give the necessary
permission to the hospital authority. I undertake to pay all the hospital and or medical expenses that may
be incurred.
MEDICAL AID DETAILS
Name: ..............................................................................................................................................................
Number: ..........................................................................................................................................................
Name of Family Doctor: ...................................................................................................................................
Practice no: .....................................................................................................................................................
Tel: ..........................................................................
Do you suffer from or have any condition that is related to chronic medical indisposition (eg. Allergies,
diabetes, epilepsy,dyslexic, hyper-tension, handicap etc)? YES NO
If YES, Specify .................................................................................................................................................
HEALTH CERTIFICATE (This section must be completed by a Medical Doctor)
I .......................................................................................................................................................... declare
that I examined ........................................................................................................................................... on
........................................................... and found him/her to be in good health, free of any handicap or
sicknesses that can prevent him/her to follow a training course at Glen Agricultural College successfully. I
realise that this course includes practical work that makes high physical demands, and that, amongst others,
his/her sight and hearing must be good to be able to utilise lectures and practicals effectively.
Comments
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
(DOCTOR’S SIGNATURE)
Practice no: ........................................................
Tel: ......................................................................
PREGNANCY DECLARATION
I .......................................................................................................................................................................
(NAME / SURNAME)
realise that the right to exercise a choice that pertains to my sexual activity is a personal responsibility, and
the Glen Agricultural College ‘s obligation towards me is of an academic nature, albeit that the College
provides counselling on health and sexual matters to the students.
I also take note that the college’s medical and social services are not geared to deal with pre-natal care and
that for the sake of a healthy pregnancy, I have to visit the appropriate institutions for this purpose at my
own cost for transport and medical fees.
I realize that if I fall pregnant, I will not have available to me the medical and social service on the campus,
and that I will be allowed to remain in the residence up to 20 weeks of the pregnancy, as specified by the
medical practitioner of my choice whence I will, for the sake of my own health and that of my unborn child,
leave the residence. If the pregnancy is only diagnosed after 20 weeks, I will leave the residence within
seven days.
I take note, after giving birth, and a room is available, I may again return to the residence. If I will be subject
to the rules and conditions that apply to other members of the residence. I realize that there are no facilities
for babies and older children in the residence, and that they, for the sake of maintaining an academic
atmosphere, will not be allowed to stay in the residence overnight or be accommodated in the residence.
(SIGNATURE)
INDEMNITY
1. I........................................................................................................................................................ hereby
(NAME / SURNAME)
1.1. declare that the information submitted in the form is true.
1.2. Acknowledge and declare that should as a result of my attending the Glen Agricultural College,
whether during or in the course of training or not, sustain bodily injury, death or suffer any damage
whatsoever to my property, as a result of the use of any transport or if caused by animals or implements or
other students or as a result of any cause whatsoever and under any circumstances whatsoever, whether
or not such injury or death or damage may arise out of or may have any connection with any negligence,
failure or incompetence on the part of any employee or officer of the State or persons acting on instructions
by an officer of the state, the State shall not be held liable to me, my assigns, my heirs and not my
dependants, I do hereby indemnify, hold harmless and absolve the State, its officers and employees and
persons acting in instructions by an officer of the State against and from any claim of damage whatsoever
and any legal expenses or costs, which may arise out of my attending the Glen Agricultural College as
aforesaid, which damage, expenses or costs may be claimed by any person whatsoever
2. I declare, agree and undertake in contract with the Glen Agricultural College
2.1. to submit myself, for the entire duration of registration as full time student at Glen Agricultural
College, to the rules and regulations as stipulated by the Head of the Institution, such rules can, without prior
notice, be modified. I undertake to abide by the rules as soon as I have received and read them.
2.2. To submit myself to any disciplinary steps which are reported against me, including the right of the
Head of the Institution to expel me due to a serious infringement, if I in his or her opinion was guilty of the
infringement of the rules or of serious misbehaviour whether on the terrain of Glen Agricultural College or
outside.
2.3. To pay, in full, the indebted money of each year, until my course is completed, or if I discontinue my
studies, to advise the Head of the Institution in writing. Fees are strictly payable in advance for every term.
2.4. In case I am expelled from the course, to remain accountable for any money which might still be
outstanding.
2.5. In case I owe any outstanding money that I will advise the Head of the Institute, in writing, of any
change of address after I have left the Glen Agricultural College.
3. This Contract will be valid and applicable for the full duration of my studies.
Signed on………………........…………..at……………………………….............................................................
(SIGNATURE)
(PARENT/GUARDIAN)
(WITNESS) (WITNESS)
The Registrar
Glen Agricultural College
Private Bag X1
Glen 9360
Tel: 051 861 8316 /
Tel: 051 861 8313