Experiential Learning Resource Officein the Division: Tuition Support (TS) — Ground-floor,00-076, NB Pityana Building, Florida campus
Private Bag X6, Florida, 1710
Tel: (011) 471 2219 / Fax: (086) 5082809/ E-mail:
Revised: 27February 2017
Please note that completion and submission of this template is voluntary in accordance to the Protection and Personal Information Act (No 4 of 2013). Please note further that a natural person under the age of 18 needs the consent, as per section 11 of the said act, of a legally competent person, such as her/his parent or guardian.
- PERSONAL INFORMATION
1.1 / Initials and Surname: / Gender:(Male/Female)
Names:
1.2 / Student number: / ID-Number:
1.3 / Postal address (home):
1.4 / Tel. No. – Student: / ( ) / Cell No: / ( )
Alternate No: / ( )
1.5 / Current physical address:
Nearest city/big town: / Region/province:
1.6 / E-mail address:
- ACADEMIC INFORMATION
2.1 / Qualification (e.g. N Dip Mechanical Engineering):
2.2 / Modules (Name and Code) registered for during
current year
2.3 / Please attach your latest academic record with a copy of your ID at the bottom of this CV. If possible forward as one document when you email it to me. You are welcome to also attach your personal CV with more detail.
3.GENERAL
3.1 / Sport: / 3.2 Hobbies:3.2 / Present activity (doing currently)
3.3 / Languages: / Other :
3.4 / Do you have a valid driver's license? / Code:
3.5 / Any disability that should be made provision for?
4.WORK PREFERENCES
4.1 / What type of work would you like to do when you complete your qualification:4.2 / Which region/province(s) are you able to undergo your prerequisite work-integrated learning?
Please indicate priority, if more than one region/province.
4.3 / Which type of operation(s) — commodity/industry — would you like to gain experience or work in?
Please indicate priority, if more than one region/province.
5.SPECIAL CIRCUMSTANCE AND/OR MOTIVATION
Use this space to sell yourself, indicate any special circumstances and/or to motivate your application for a work-integrated learning opportunity.
The data subject (the natural person to whom the information voluntarily disclosed herein) acknowledges and gives Unisa permission – as per conditions 3 & 4 of the POPI Act – to present the information to potential Experiential Learning Providers (ELPs), as per Unisa’s Experiential Learning Policy and Procedural Manual. The purpose of such further processing of the information would be to facilitate a work-integrated learning (WIL) placement where WIL forms a credit-bearing part of the curriculum of the student.
Signed by STUDENT
Signed at ______on this ___ day of ______201__ in the presence of the undersigned witnesses
Witnesses:
1.Signature: / Student’s signature:
Name in print:
2.
Signature / Name in print:
Name in print: