Lemang Course Enrolment Form - AFGRI Production

Course Selection

Select the course you are applying for*

How Did You Hear About Us

Indicate other courses you are Interested In (multiple selection available by pressing Command on your keyboard and selecting each course on the list below)*

Learner Details

First Names*

Surname*

Initials*

Title*

ID Number*

Date of Birth*

Gender*

Home Language*

Province*

Region*

Nationality*

Citizenship Status*

Disability Status*

Special Needs*

Employment Status*

Learner Contact Details

Cellphone Number*

Home Telephone Number

Fax Number

Email Address*

Enter Email Confirm Email

Preferred Method of Communication*

Residential Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Academic Record

Highest Qualifications (Main Subjects)

Employer Details

Employer (Company Name)

Direct Supervisor (First Name and Surname)

Telephone Number

Cellphone Number

Email Address

Emergency Contact Details

First Name and Surname*

Telephone Number*

Cellphone Number*

Next of Kin Contact Details

First Name and Surname*

Relationship*

Telephone Number*

Cellphone Number*

Residential Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Accomodation Booking

Accommodation Requirements*

Payment Details

Person Responsible (First Name and Surname)*

Telephone Number*

Email Address*

Consent and Security

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