/ LEARNER REGISTRATION FORM
(SKILLS PROGRAMMES, SKILLS SET & UNIT STANDARDS)

(Attach an originally certified copy of ID document and proof of highest qualification)

LEARNER DETAILS
Title / First Names / Surname
I.D. No / Are you a South African citizen? / Y / N / Citizenship
Date Of Birth / Yyyy / Mm / Dd / Gender / Male / Female
Race
African / Coloured / Indian / White / Other
Disability / Y / N / Specify
Union Membership / Y / N / If yes, please specify union
Do you live in a Rural or Urban Area? / Urban / Rural
Home Address / Postal Address
City / City
Post Code / Country / Post Code / Country
Province / Mag. District
E-Mail / Phone / Code / Number / Cell
Highest Level Qualification
Title of Highest Qualification

Language

/ Speak / Read / Write
Home Language / Y / N / Y / N
Other Language 1 / Y / N / Y / N / Y / N
Other Language 2 / Y / N / Y / N / Y / N
LEARNING PROGRAMME DETAILS
NAME OF SKILLS PROGRAMME/SKILLS SET/SKILLS SET REGISTERED FOR
REGISTRATION CODE OF SKILLS PROGRAMME/SKILLS SET REGISTERED FOR
TITLES AND UNIT STANDARD(S) CODES
(RELEVANT IN CASE OF UNIT STANDARD REGISTRATIONS ONLY)
SAQA UNIT STANDARD TITLE / SAQA UNIT STANDARD CODE
Name of Project and Code linked to Skills Programme /SKILLS SET and Unit standard
Commencement Date
Completion Date

LEARNER EMPLOYMENT DETAILS

Legal Name of lead Employer

Trading name of lead Employer
LEADEmployer Workplace
Workplace approval / YES / NO
SDL Number
Name of Seta Registered at
SIC code that applies
Contact Person / Telephone Number
Supervisor Name
Learner’s Current Job
Were you employed by your employer before concluding this form? / Employed / Unemployed
If you were unemployed before concluding this form , state how long
Employment History / Dates / Position / Description
Skill Area
Notes
LEARNER EMPLOYMENT DETAILS
LEGAL NAME OF HOST EMPLOYER
TRADING NAME OF HOST EMPLOYER
HOST EMPLOYER WORKPLACE
WORKPLACE APPROVAL / YES / NO
SDL NUMBER
NAME OF SETA REGISTERED AT
SIC CODE THAT APPLIES
CONTACT PERSON / TELEPHONE NUMBER
LEAD TRAINING PROVIDER DETAILS

Legal Name of Skills development Provider

Trading Name of Skills development Provider

Skills development Provider site
SDL Number
Name of Seta Registered at
SIC code that applies
Contact Person / Telephone Number
Accreditation Number / Review Date
Physical Address / Postal Address
City / City
Post Code / Country / Post Code / Country
Province / Mag. District
E-Mail / Phone / Code / Number / Cell
PARENT OR GUARDIAN DETAIL (to be completed if learner is a minor – i.e. an unmarried person under 21 years)
Title / First Names / Surname
I.D. No
Home Address / Postal Address
City / City
Post Code / Country / Post Code / Country
Province / Mag. District
E-Mail / Phone / Code / Number / Cell
DECLARATIONS AND SIGNATURES

I hereby declare that the capturing of the abovementioned information is accurate.

5.3SIGNATORIES:

Learner’s Signature / Witness Signature
Date / Date
LeadSkills Development Provider’s Signature
(Delete the word ‘Lead’ if not applicable) / Witness Signature
Date / Date
Employer / Date

SKILLS PROGRAMME/SKILLS SETEVALUATION CHECKLIST

Name of applicant: / ID Number:
Application correctly completed
Skills Programme/Skills Set Clearly Specified
Application signed by all parties (employer, Skills development provider,learner) and witness
Corrections initialled by all parties
No Tippex used
Applicant is SA citizen
Correct ID number and name and original certified copy attached
Commencement and completion date reflected on registration form
Physical address for both employer/Skills development provider and learner completed
Highest qualification indicated and original certified copy attached

All of the above criteria must be met before any application is accepted by any merSETA official.

I hereby confirm that all the details required for registration as stipulated above are attached and complied with and the information required is correctly captured on SMSand corresponds with details as reflected on the application form.

NAME OF EMPLOYER/REPRESENTATIVE

SIGNATURE

DATE

Return completed application form to: the relevant regional office.

FOR merSETA OFFICE USE
  1. Registered at the office of the MERSETA on the

Day of / (month)
(year)

NAME OF REGIONAL MANAGER

SIGNATURE

  1. ON COMPLETION

This is to certify that the Learner

Has completed all prescribed training, modules and assessments in the Skills programme or Unit Standard(s) of:

COMPLETION DATE / day of / (month) / (year)
NAME OF LEARNER
Learning programme NUMBER
NAME OF REGIONAL MANAGER
SIGNATURE
Document Title / Skills Programme Learner Registration Form
Document Number / LPM-FM-015 / Date Compiled / 01 July 2008
Page Number / Page 1 of 6 / *Last Revision Date / 30 March 2016
Revision Number / Rev 07 / Access / Controlled

21 October 2018 *The document with the latest revision date is the current official document