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Fee Liability
1/We (employer/sponsor/other) Confirm that I/ we am/ are liable for the fees of applicant. Signature of account holder: Title: MISS Telephone : (home) ( lnitial(s): LR } _ Signature of second account holder (if required): Title: Telephone : (home) ( lnitial(s): } Date: Surname: Telephone (work) ( ) _ _ _ Date: Surname: MAFATLE _ _

REGENT
Business School
Dam=---------Study options Please tick the appropriate box: X Master of Business Administration (MBA)

REGISTRATION FORM

Telephone (work) (011)9338534

STAPLE YOUR

DDistance

DRich Distance

2
PHOTO'S

I,the undersigned applicant do hereby : Acknowledge that Ihave familiarised myself with the prospectus to the relevant degree and certify that the information given in this form is accurate and complete in all respects. Undertake to bind myself to Regent Business School, to pay in full, all fees and other charges due and payable by myself in terms of the relevant applicable annual schedule of fees.
Agree that Regent Business School reserves the right to withhold all/ any module results, resulting from any default in payment of all/ any fees according to this signed Registration Contract, agree that the Regent Business School shall be entitled to recover from me all/ any legal costs incurred in order to enforce its right under this contract including, but not by way of limitation, attorneys and own client fees, collection charges and all tracing charges and, agree that the creditor herein may approach credit agencies with a view of ascertaining the applicant's credit record and that in the event of the applicant being in arrears with this account or failing to pay it, that the company shall have an irrevocable right to inform credit agencies thereof. Ialso accept that I have to satisfy the requirements of due performance as laid down by Regent Business School and agree that my details will be made available for other students for the purpose of forming study groups. Declare that all particulars furnished by me on this form are true and correct, and Iundertake to comply and abide by the rules, regulations and decisions of Regent Business School, and any amendments thereto.

HERE

D D D D

Post Graduate Diploma in Management Post Graduate Diploma in Educational Management and Leadership Bachelor of Commerce Honours Bachelor of Commerce Degree (BCOM)

The following must accompany this registration form: A certified copy of the first page of your Identity Document or passport TWo passport-sized photographs A copy of your Curlculum VItae (new students only)

D Diploma in Human Resource Management D Diploma in Financial Management D Higher Certificate in Accounting D Higher Certificate in Management for Estate Agents D Higher Certificate in Health Care Services Management D Certificate in Business Management D Certificate in Entrepreneurship

CANCELLATION OF REGISTRATION
A student intending to cancel his/her registration during a semester must inform the specific student support programme coordinator of Regent Business School, in writing. All cancellations are subject to approval of Regent Business School. The cancellation of registration is effective only after a written approval has been forwarded to the student after the student has completed all the necessary documentation regarding cancellation of studies.

New Student

D Year 1
Section A Applicant's personal details Title: MISS
First Name(s): LIM PHO R EBEC A C ID number: 8504260582088

D Returning Student D Year2

Elective 1:

_ _

X Year3

Elective 2:

RULES REGARDING CANCELLATION FOR STUDENTS I SHOULD A STUDENT CANCEL HIS/HER REGISTRATION, On or before 30 calendar days, commencing from date of initial deposit payment, he/she will be liable for 50% of the programme fee according to the selected payment plan. After 30 calendar days, commencing from date of initial deposit payment he/she will be liable for 100 % of the fee according to the selected payment plan.
Signature of Applicant:--------LMAFATLE--------Signature of sponsor/ company representative/ other (if applicable): _ Title: lnitial(s): Surname: _ Witness: Date: _ Title: lnitial(s): Surname: _

lnitial(s): LR

Surname: MAFATLE Gender: D Male X Female Nationality: ( RSA, etc) RSA

_ _ _ _

Passport number (if no identity document):, Date of Birth: 19850426 Disability (if yes) type: Race: AFRICAN/BLACK NO Home language: SOUTHERN SOTHO _

Applicant's Address Postal address: PO Box number: 5 0 6

Country: SO HAF IC UT R A

Suburb: L A DYB R A N D

Code: 9745 Code:

_ _

Regent Business Schoolcontact details Kindly forward the Registration Form with the requisite documents to:

Physical address: Unit/flat/complex number and name-503 DUNKELD MANSIONS, 235 OXFORD RD, ILLOVO, 2196, JOHANNESBURG 304

Durban
35 Samora Machel Street, (Aiiwal St) Durban, South Africa P.O.Box 10686, Marine Parade 4056 South Africa

Tel: +27 (0) 31 304 4626/ Fax:+27 (0) 31 7303 Email:study@regent.ac.za

Johannesburg 2nd Floor, Sunnyside Centre 13 Frost Avenue, Sunnyside,Auckland Park P.O.Box 291353,Melville, Johannesburg 2109 SoU1h Africa

Accredltlld by lhe Council on Higher Education (CHE) and Registered with1he Depar1ment of Higher EduceUon and Training (DoHET) Reglslradon No.2000/HE07/012

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Tel: +27 (0) 11 482 1404/ Fax: +27 (0) 11 482 5299 Email: studyjhb@regent.ac.za

Street number and name: Suburb:-----------------------City:----------- Code:

Province:

country:

How did you hear about REGENT BUSINESS SCHOOL-------------------

Accredltlld by lhe Council on Higher Education (CHE) and Registered with1he Depar1ment of Higher EduceUon and Training (DoHET) Reglslradon No.2000/HE07/012

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Applicant's contact details National code if outside SA: 0735713671Facsimile: ( ) 0866175592 Email Address: l i m p s m a f a t l e @ g m a i l . c o m Cellphone: -Telephone: (work) ( 0119338534 _ Telephone: (home) ( ) ) _

Please indicate your choice from the following payment plan:

D Cash

plan with this registration form. InitialDeposit with this registration form and the balance to be paid, as stipulated in the current fee schedule. Initial Deposit with this registration form and the balance to be paid, as stipulated in the current fee schedule.

Plan A Initial Deposit with this registration form.

D Plan B X Plan C

Payments must be made on or before due dates as stipulated in the fee schedule. Applicants Courier address Physical delivery address: (Please note that this must be a physical address where someone will be available to collect your study material) Physical address: Unit/flat/complex number and name 5 0 3 D U N K E L D M A N S I O N S Street number and name 2 3 5 O X F O R D R O A D Suburb ILLOVO Code. 2196 Province. GAUTENG City J O H A N N E S B U R G _ Country SOUTH AFRICA _ Debit Order Next of kin details (Relative/friend not living with you) Name: S A N D H Y A N A I D O O Address: Tel: 0835966235 Section B Academic qualifications E-Mail: I hereby authorize Regent Business School to draw against my bank account for the installments necessary to pay the fees. _ _ _ The monthly instalments can be drawn on my salary date each month. The first installment to be the calendar month following receipt of this notice. The instruction will remain inforce until my account with Regent Business School has been settled in full. I agree to pay any bank charges relaying to his debit order instruction. Receipt of this instruction shall be regarded as receipt thereof by my I our bank (whichever it is or will be). Details of account holder Title: lnitial(s): First Name (s): Bank: Branch: Branch Code: _ _ _ Please Indicate haw fees will be paid:

Direct deposit Account name Branch Code

:On or before the due date of accessed installments into the Regent Business School Account. :Regent Business School :04 26 26 10 Bank: Standard Bank Branch: Musgrave Road Account number:05 124 5485

D Direct payments

: At Regent Business School offices in cash or by cheque on or before the due dates.

Cellphone/ telephone number of addressee: 0735713671

Institution
DURBAN UNIVERSITY OF TECHNOLOGY

Qualifications
BTECH: CLINICAL TECHNOLOGY

Completed(YIN)
2008

Year completed No.of years

Surname:

_ _ _

----------------------------------------

Account Number: Current employment Present employer: CHB HOSP----- Commencement Date:2010--- Current job title: CLINICAL TECHNOLOGIST --------- Contact person: MRS NAIK (011)9339270 Please indicate the region in which you will be writing examinations and attending workshops Durban Swaziland Other* Sector: HEALTH-Telephone: (work) Details of second account holder (if second signature is required on account) Title: Namibia lnitial(s): Surname: Date: _ _ _ Eastern Cape Company name:(if business is the account holder) Signature of account holder: Date: _ _

D D

Johannesburg X Zambia

FirstName(s): Signature of account holder:

----------------------------------------

A cancelled cheque should be attached for identification purposes (current accounts only). Credit Card Credit card budget account - Please tick the number of months required

*OTHER VENUES WILL BE SUBJECT TO APPROVAL BY THE REGENT BUSINESS SCHOOL EXAMINATION BOARD. COSTS MAY BE INCURRED BY STUDENT. Please indicate whether your contact details may be given to other students in your region. Section C Payment Plan Please tick the appropriate box: Self X Company* Sponsor**

YES X

D 6 months
NO D

12 months

18 months

D 24 months
_ to my credit card account. _ Last 3 digits of eve number: _ Express

I authorise you to charge the full course fee of R Credit card number: Expiry date:---- D VISA

MasterCard

D Diners

D American

payment.

*It is essential that you enclose an:*official company letterhead authorizing payment,** sponsor's letterhead authorizing
Accredltlld by lhe Council on Higher Education (CHE) and Registered with1he Depar1mant of Higher EduceUon and Training (DoHET) Reglslradon No.2000/HE07/012

Title: MISS

lnitial(s): LR _

Surname: M A F A T L E _ Signature: Date: _

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First Name (s): L I MP H O R E B E C C A

Accredltlld by lhe Council on Higher Education (CHE) and Registered with1he Depar1mant of Higher EduceUon and Training (DoHET) Reglslradon No.2000/HE07/012