Course Registration Form – Fastbrand Demo Site

WELCOME

Please review carefully and fill out all applicable fields, this will allow us to finalize the enrollment process. This form should take +-15 minutes to complete. Once you’ve registered, you’ll be able to submit transcripts and other information to complete your enrollment.

STUDENT DETAILS

Personal Contact information

FIRST NAME (LEGAL NAME)

MIDDLE NAME

LAST NAME (LEGAL NAME)

NICK NAME

EMAIL ADDRESS

OTHER EMAIL ADDRESS

PRIMARY PHONE

GENDER

Male

Female

Not Specified

DATE OF BIRTH

SELECT DATE ×

Phone Contact

SECONDARY PHONE

ADDITIONAL PHONE

PREFERRED CONTACT METHOD*

TIME TO BE REACHED*

HOME LANGUAGE

NATIONALITY

Other Language*

Write Here

Physical Address and Contact

CITY / TOWN

STREET / AREA / BLOCK

STATE / PROVINCE

COUNTRY

SUBURB / AREA

AREA CODE

Next of kin

RELATIONSHIP

NEXT OF KIN NAME & SURNAME

NEXT OF KIN PHONE

Course*

Username

Password

Text Input Title*

Write Here

Text Input Title*

Write Here

Text Input Title*

Write Here

STUDENT ID / PASSPORT NUMBER

Id Passport

STUDENT ID / PASSPORT NUMBER

DID A REPRESENTATIVE ASSIST YOU THROUGHOUT THE PROCESS OF BECOMING A STUDENT?

Yes

WHO HELPED YOU THROUGH THE PROCESS?

SPECIFY WHO ELSE

SPECIFY OTHER

SPECIFY METHOD OF SELF-SERVICE

Write here

DID YOU RECEIVE A DISCOUNT CODE?

Yes

DISCOUNT CODE

ENTER YOUR DISCOUNT CODE HERE ex. 0822-20yr

respondid*

respondid

REQUIRED STATISTICAL DETAILS

DO YOU HAVE ANY DISABILITIES?

Yes

SPECIFY DISABILITIES

DO YOU HAVE ANY ILLNESS?

Yes

SPECIFY ILLNESS

DO YOU HAVE ANY SPECIAL NEEDS?

Yes

SPECIFY SPECIAL NEEDS

AGE GROUP

RACE

T-SHIRT SIZE

DO YOU OWN A COMPUTER?

Yes

SPECIFY OPERATING SYSTEM

WHERE DID YOU HEAR ABOUT US?

SPECIFY OTHER

NAME YOUR IDOL / HERO*

Type here

WHY DID YOU DECIDE TO STUDY AT EMENDY?

WHAT DO YOU WANT TO ACHIEVE BY STUDYING THIS COURSE?

ACADEMIC INFORMATION

IN WHICH COUNTRY DID YOU ATTEND HIGH SCHOOL?

Country

IN WHICH CITY DID YOU ATTEND HIGH SCHOOL?

Write Here

SCHOOL NAME

GRADUATION YEAR*

1978

HIGHEST QUALIFICATION

FINANCE OPTIONS

Payee Details

WHO WILL BE FUNDING YOUR STUDIES?

SELECT A PAYMENT OPTION*

PAYEE NAME & SURNAME

PAYEE EMAIL

PAYEE PHONE

Select a Funding Provider*

FUNDING PROVIDER NAME

FUNDING PROVIDER EMAIL

FUNDING PROVIDER PHONE

TERMS AND CONDITIONS

Signature

I , with ID / Passport Nr am fully aware that the programme I have enrolled on, that is, , is registered with the South African Department of Higher Education and Training to Belgium Capus, as indicated on the registration certificate dated {add date} and agree to accept the Terms & Conditions

I , with ID / Passport Nr am fully aware that the programme I have enrolled on, that is, , is registered with the South African Department of Higher Education and Training to EMENDY PTY (Ltd), as indicated on the registration certificate dated 3 December 2019 and agree to accept the Terms & Conditions

I , with ID Number am fully aware that the programme I have enrolled on, that is, %104%, is registered under Fastbrand Technologies and agree to accept the Terms & Conditions