Winter School 2019 Application form
Title
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Surname *
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First Names *
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Postal Address *
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City/Suburb *
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Postal Code *
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Region/ Province *
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Country *
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Telephone number (Home) *
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Telephone number (Work) *
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Mobile number *
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Fax Number
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Email Address *
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Date of Birth *
MM
/
DD
/
YYYY
National ID number (compulsory for South African citizens)
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Passport number (Foreign)
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Gender *
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Employer Address details
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Occupation
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Current position (if employed)
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Briefly describe your responsibilities in your present position
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How many years of full-time public/community health or related experience
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EDUCATIONAL QUALIFICATIONS (highest school grade and tertiary qualifications)
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Are you currently enrolled in Public Health programme? If yes, at which institution?
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