ALL APPLICANTS MUST COMPLETE THIS FORM

Application for Undergraduate Admission in 2013

Please return form to: Student Enrolment Centre, University of the Witwatersrand, Private Bag 4, Wits 2050 or deliver to Ground Floor, Senate House, Jorissen Street, Braamfontein

A non-refundable application fee is payable: R300 for South African citizens and R680 for International applicants. Refer to pages 7 and 8 for more information. Please note: Photocopied applications will not be accepted as the payment reference number is unique. Also do not enclose cash and postal orders if returning by post.

CHOICE OF PROGRAMME (DEGREE)

Please supply details on proposed registration. Applicants may select three programmes. Names and programme codes appear on page 8.
Programme Code Year of study Please indicate plan if applying for Bachelor of Health Sciences ONLY Plan 1 Plan 2 Plan 3

Please ensure the correct code, as indicated on page 8 of this form, is used when completing this programme.

Have you applied to Wits before? Yes

No

Have you enrolled (registered) at Wits before? Yes

No

If yes, please quote student/person number

PERSONAL DETAILS Please use capital letters

Title Mr Miss Ms Other

Last name/Surname First name Gender (please tick ) Female Date of birth
Day Month (e.g.Dec) Year

Middle name/s Male

CITIZENSHIP
Are you a South African citizen?/ a permanent resident? Yes
If yes, attach certied proof of SA ID or PR document

No

South African Identity no. If not South African permanent resident, state nationality Supply passport number If not South African permanent resident, state the country you have permanent residence in Indicate your Immigration status (where applicable) Assylum Seeker Refugee ME BQ FA AT RES
BANKSLIP

PAYMENT INFORMATION (FOR OFFICE USE ONLY)

CASH CHEQUE/ BANK DRAFT OTHER

CREDIT CARD

Received by:

_______________________________________________

Date: Date:

_____________________________________________________

Processed by:

______________________________________

__________________________________________

CLOSING DATE FOR HEALTH SCIENCES AND BA SPEECH AND HEARING: 30 JUNE 2012 CLOSING DATE FOR BACHELOR OF ARCHITECTURE: 30 JUNE 2012 CLOSING DATE FOR OTHER DEGREES, FINANCIAL AID AND APPLICATIONS FOR RESIDENCE: 31 AUGUST 2012

Application for Undergraduate Admission: All applicants to complete

DETAILS OF CHANGE OF NAMES IF ANY

Name change (if applicable) Previous rst name (if applicable) Date of name change
Day Month (e.g.Dec) Year

Previous surname (if applicable) Reason for name change

GENERAL BACKGROUND
Population Group
(Please tick ) (Required for statistical purposes)

Black Sepedi SeSotho

Coloured

Indian Marital status

(Please tick )

White Single Married Widow/er Divorced Separated

Chinese

Home Language
(Please tick )

Afrikaans English Chinese French German Greek Ndebele Italian Portuguese

Setswana Siswati Sixhosa Isizulu Tshivenda Xitsonga Other (Please specify):

Religious afliation (Required for accommodation and bursary purposes) (Please tick ) Christian Hindu Muslim Jehovahs Witness Jewish None Other (Please specify)

Disability/Special needs*
(Please tick )

Blindness Deafness Partial hearing Partially sighted Other (Please specify:)

ADD/ADHD (chronic) Learning disability e.g. Dyslexia Speech

Cerebral palsied Impaired mobility Paraplegic Quadriplegic

In order for the University to provide you with the necessary services, we need you to indicate your disability status at the time of your application. If you do not, the University cannot undertake to provide such assistance. Every reasonable attempt will be made to provide you with the assistance you may need as a result of your disability.

PREVIOUS ACTIVITIES
What has been your MAIN ACTIVITY in 2012? (e.g. working/student/school). (Please tick )

University

College

School

Employment

Gap Year (maximum one year after matric)

Sports Involvement: (please state in which sports you have participated if any and at what level)
Sport 1. 2. Level (School, Club, Junior/Senior Provincial; Junior/Senior National)

CONTACT DETAILS (ALL DETAILS MUST BE COMPLETED)

Applicants physical address City Province Country Applicants postal address City Province Country Contact numbers Home Cell no. Email Next-of-kin details: relationship e.g. Mother or Father............................................................................................... Surname Initials ID no. Next-of-kin postal address City Province Country Contact numbers: Home Cell no. Email Person liable for settlement of fees (Person to sign on page 7) Surname Initials ID no. Person liable for fees Address details City Province Country Contact numbers: Home Cell no. Email Business Fax Postal code First name Title Business Fax Postal code First name Title Business Fax Postal code Postal code

Application for Undergraduate Admission: All applicants to complete

ACADEMIC HISTORY

SOUTH AFRICAN QUALIFICATIONS

If you have MATRICULATED / HAVE ATTEMPTED MATRIC, please submit a certied copy of your matric certicate.

SCHOOL ATTENDING/ATTENDED Name of School Address of School Postal code Telephone

GRADE 11 RESULTS - TO BE COMPLETED BY APPLICANTS WRITING THE NSC/CURRENTLY IN MATRIC IN 2012

Supply nal Grade 11 results / Grade 11 report only SUBJECTS e.g. English First Language
1. 2. 3. 4. 5. 6. 7. 8.

PERCENTAGE e.g. 50%

School Stamp

____________________________________
Signature of Principal or Authorised Deputy

You may also attach a copy of your nal Grade 11 report certied by a Commissioner of Oaths.

GRADE 12 PARTICULARS - TO BE COMPLETED BY APPLICANTS WRITING FIRST ATTEMPT MATRIC IN 2012

School at which examination will be written Examination number NSC Subjects to be written in 2012
1. 2. 3. 4. 5. 6. 7. 8.

Application for Undergraduate Admission: All applicants to complete

GRADE 12 PARTICULARS - TO BE COMPLETED BY UPGRADING APPLICANTS

Date (month) examination will be rewritten in 2012 School at which examination will be written Examination number NSC Subjects to be written in 2012
1. 2. 3. 4. 5. 6. 7. 8.

ALL MATRICULANTS - EXAMINING AUTHORITY (PLEASE TICK

Gauteng Eastern Cape Mpumalanga KwaZulu-Natal Northern Cape Limpopo North West Free State

Western Cape IEB

INTERNATIONAL QUALIFICATIONS
Have you completed your qualication? Yes If yes, PLEASE SUBMIT CERTIFIED COPIES OF SCHOOL LEAVING CERTIFICATES If qualication to be written in 2012, please complete section below Month (e.g. November) Examining Authority Exam no. No Complete this section only if you are writing or have written a NON-SOUTH AFRICAN EDUCATIONAL QUALIFICATION and require exemption from the Matriculation Board

Centre no.

A-Level (Subject)

AS-Level (Subject)

HIGCSE (Subject)

If A, AS and HIGCSE levels are not applicable to you, please supply details in this column

Application for Undergraduate Admission: All applicants to complete

PREVIOUS AND CURRENT TERTIARY AND OTHER QUALIFICATIONS

Tertiary education including studies at Wits (begin with most recent qualication): Certied copies of academic transcripts and code of conduct must be attached for all applicants except for those with Wits qualications. You are required to disclose all tertiary registration, even if you de-registered in the course of the year. Dates of Degree/ Diploma FT or PT * Registration from to Date of Graduation Student Number Institution Status:
P (passed); F (Failed); C (still to complete year/results not available); Z (cancelled)

* FT = full time PT= Part Time

RESIDENTIAL ACCOMMODATION Do you wish to apply for University Residence Accommodation?

If yes, please complete this section You must complete this section ONLY IF YOU WANT TO APPLY FOR RESIDENCE ACCOMMODATION AND YOU ARE NOT ALREADY A WITS STUDENT. If you are already a Wits student and you want to apply for residence accommodation, you should apply directly to your preferred residence in person. Accommodation available (please tick the appropriate box):
Catering accommodation - Males only
CTM

YES

NO

Catering accommodation - Mixed gender

Over 19 years of age only

CTX

Catering accommodation - Females only

CTF

Self - catering accommodation** Mixed gender

Not available to 1st year students under the age of 21 years

SCX

If you are a rst year student and are admitted to University accommodation, you will have to share a room.

PLEASE NOTE: Residence applications close on 31 August 2012. Late applications will not be considered. You are NOT eligible to reside in University accommodation if you are not registered for a full-time curriculum or if you are a part-time or occasional student.

Application for Undergraduate Admission: All applicants to complete

INDEMNITY AND UNDERTAKING
Applicants under the age of 18 years old must be assisted by their parent or guardian, (must be the same person listed under next-of-kin on page 3).

LEGAL DECLARATION OF INDEMNITY AND UNDERTAKING

I, THE APPLICANT, AND I, THE PARENT/GUARDIAN /NEXT-OF-KIN OF THE APPLICANT
(1) Acknowledge that the University does not accept responsibility for damage or loss in respect of property of the applicant or in respect of property brought onto University premises by the applicant. (2) Do hereby indemnify the University in respect of any damage caused by the applicant to University property or to the property of third parties, whether on or off the University premises, as a result of the applicants actions either whilst on the University premises or whilst engaged in any activity related to the University. (3) Undertake, during the orientation period and for any period during which I am a registered student, to be bound by the rules and regulations of the University for the time being in force, including the rules and regulations of any University residence, club or society to which I may be admitted or become a member and by any requirements or conditions imposed by the University on me as a prerequisite to my registration as a student of the University in any faculty. (4) Certify that the information provided in this form and all supporting documentation is accurate and acknowledge that furnishing any false information may result in disciplinary proceedings being taken against the applicant. (5) Declare that I have furnished the University with all the information necessary to make an informed decision about my admission. (6) Undertake to pay unconditionally all fees, charges and equipment surcharges payable to the University as they fall due for payment for any period for which I am or may become a registered student or the applicant is or may become a registered student of the University. (7) Consent to my examination results being made available to the relevant bursary donor(s) and/or lenders. (8) Understand that if I am unable or unwilling to accept the terms and conditions of the offer of a loan, the offer will be withdrawn. *Bursary and/or loan recipients delete if not applicable.

ALL APPLICANTS MUST SIGN BELOW - Thank you Signature of applicant:.................................................. ..................................................................................... First name Signature of parent/legal guardian:............................... Date: .............................................. ....................................................... Last Name/Surname Date:............................................... AND, if the applicant is under the age of 18 years, assisted by (Full name of parent or legal guardian or next-of-kin):

PERSON LIABLE FOR SETTLEMENT OF FEES I undertake to settle all tuition and miscellaneous fees due to the University by due date. I may make suitable arrangements to settle the outstanding charges as per the Universitys Credit Policy as stipulated by the National Credit Regulator. If I do not settle by due date, I will pay interest at the rate prescribed by the University. I also consent to the University imposing credit control restrictions if the debt is not settled.

Full name:..................................................................... Date:............................................................................

Signature.....................................................................

Application Fee and Payment

ALL APPLICANTS are required to pay an application fee of R300 (R680 for international applicants). Methods of payment: 1. Deposit exact amount into Universitys account: Standard Bank, Current Account Number: 200 346 385, Branch code: Braamfontein 004 805. CI Number 074A, Account name: Wits University - Application Fees. Please attach copy of M65. 2. Cheque/postal order/bank draft made out to The University of the Witwatersrand. Write applicants name on the back. 3. Pay by cash or credit card at the Fees Ofce, Ground Floor, Senate House, University of the Witwatersrand. 4. For EFTs Use Reference: Initials and Surname.

Programme (degree) codes

CB000 CB005 CB008 LF014 Bachelor of Science in Occupational Therapy Bachelor of Pharmacy Bachelor of Dental Science MF003 MF004 MF005

COMMERCE & LAW

Bachelor of Commerce Bachelor of Economic Science Bachelor of Accounting Science Bachelor of Laws

HUMANITIES (ALSO EDUCATION)

Bachelor of Arts Bachelor of Arts in Dramatic Art Bachelor of Arts in Fine Arts Bachelor of Arts in Performing and Visual Arts Bachelor of Music Bachelor of Social Work Bachelor of Arts in Speech and Hearing Therapy Bachelor of Education Foundation Phase Teaching Senior Primary Teaching Secondary Teaching AB000 AF000 AF001 AF003 AF002 AF004 AF005

ENGINEERING & THE BUILT ENVIRONMENT

Bachelor of Science in Engineering (Aeronautical) Bachelor of Science in Engineering (Chemical) Bachelor of Science in Engineering (Civil) Bachelor of Science in Engineering (Electrical) Includes Information Engineering) Bachelor of Science in Engineering (Mechanical) Bachelor of Science in Engineering (Industrial) Bachelor of Science in Engineering (Metallurgy and Materials Engineering) Bachelor of Science in Engineering (Mining) Bachelor of Science in Biomedical Engineering Bachelor of Engineering Science in Digital Arts
1

EF006 EF000 EF001 EF003 EF005 EF007 EF008 EF009 EB000 EB001

HF000 HF001 HF002

SCIENCE
Bachelor of Science (General) Bachelor of Science in the eld of: Actuarial Science Chemistry with Chemical Engineering Nuclear Sciences and Engineering Metallurgy with Materials Science Applied Computing Mathematical Sciences Geological Sciences Geography and Archeological Science Biological Sciences Physical Sciences Computing and Mathematics Natural Sciences SB000 SB003 SB004 SB005 SB006 SB007 SB008 SB009 SB010 SB011 SB012 SB013 SB014

You may apply for more than one branch of the BSc(Eng). However, if you apply for Aeronautical, Industrial, or Mechanical Engineering, you may only select ONE of these branches (the curriculum for these branches is identical in the rst two years of study).

Bachelor of Architectural Studies Bachelor of Science in Urban & Regional Planning Bachelor of Science in Construction Studies

FB000 FB001 FB004

HEALTH SCIENCES
Bachelor of Health Sciences - BioMedical Plan - Human Sciences Plan - Biokinetics Plan Bachelor of Clinical Medical Practice Bachelor of Medicine & Bachelor of Surgery Bachelor of Nursing Bachelor of Science in Physiotherapy MB000

MB001 MF000 MF001 MF002