Learner Registration Form Personal Contact Course Medical Review Personal information First Name * Surname * ID / Passport Number * Date of Birth Gender Nationality Home Language Race DisabilityNoYes Disability Details Contact and emergency details Residential Address * City / Town * Province * Postal Code Mobile Number * Alternative Contact Number Email Address * Emergency Contact Full Name * Relationship * Emergency Contact Number * Alternative Emergency Number Emergency Residential Address Course and employment Course Name * Unit Standard Training Start Date Training End Date Course Duration Has Driver LicenceNoYes Licence Code Current Employer Job Title Work Address Employer Contact Number Employer SponsoringNoYes Medical information Epilepsy or seizures Yes NoAsthma Yes NoDiabetes Yes NoSevere allergies Yes NoHeart conditions Yes NoMedication affecting concentration Yes NoFainting or blackouts Yes No Other Medical Details Previous Mining Experience Previous Training Review and submit Review your details before you submit. Required fields must be completed before the final step can be submitted. I consent to POPIA processing for this application. * I confirm the information provided is true and correct. * Back Next Submit Application
