APPLICATION AND REGISTRATION FORM Tel (011) 403-5483/4/5; Fax (011) 403-3237; P O Box 890695 Lyndhurst 2106 South Africa; Reg: CK 93/22525/23 11th Floor, Orion House, 49 Jorissen Street, Braamfontein; E D Stillerman Principal & CEO, Others on inquiry
Personal Details
Surname		First Names		Title
ID/Passport #		Date of Birth		Age
Course
Starting Date		Full-Time Part-Time Flexi-Study Seminar
Subjects			Prior Qualifications
Years, Subjects & Marks
Postal Address
City		Country		Code
Telephone (H)		Fax
Telephone (W)		Cell		Email
Employer or Person responsible for Fees Payment Details
Employer / Person Person Responsible for Fees
Postal Address
City		Country		Code
Telephone (H)		Fax
Telephone (W)		Cell		Email
Course Fees
(See Course Fees Here)
Tuition Fees		50% Deposit		Balance
Fees are not refundable & Exclude Books and External Fees Est
Date Due		Date Paid
Payable	x	months up to 5 months to
Payment Options
EFT Payments To:	London School		Card Type	Select ... Master Card Visa
	Bank: Nedbank		Credit Card Number
	Branch Number: 195005		Expiry Date
	Account Number: 1950535665		CVV
			Name on Card
Signatures
I/We the above named student and person responsible for fees confirm that I/We have read and am/are bound by this Registration Form as a contract of enrolment and by the rules of the institutions including fees, good conduct and confidentiality.
Student			Person Responsible for Fees
Date			Date
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