Intake being applied for:
Programme being applied for: (please tick)
This form should be completed by the applicant. ALL pages and sections MUST be completed in full.
Date of Birth
Will you have your own transport during your first year of studies at the ICA?
Where and how did you hear about the ICA?
School / College
Year of Qualification
Town / City
School / College Tel.
Nature of Business
Have you had any serious illness during the past five years?
Please specify if applicable
Have you had any serious injury during the past five years?
Are you presently undergoing any medical treatment?
Do you take any medication on a regular basis?
Are you covered by a registered Medical Aid Fund?
Name of Fund
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