Application For Restoration - South African Nursing Council Page 2

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APPLICATION FOR RESTORATION – PAGE 2
ADDITIONAL CONTACT DETAILS
Home telephone
(
)
Cell phone (mobile)
(
)
Work telephone
(
)
Fax number
(
)
E-mail address
STATISTICAL INFORMATION
(unless otherwise indicated, mark ONE block in each section with a cross “X”)
Eastern Cape
Mpumalanga
Province in which you live
Free State
Northern Cape
Gauteng
North West
KwaZulu Natal
Western Cape
Limpopo
African
Indian/Asian
(Department of Labour codes)
Employment equity code
Coloured
White
South Africa
Zaire
Nationality
Angola
Zambia
Botswana
Zimbabwe
Lesotho
Malawi
Rest of Africa
Mauritius
Asian Countries
Mozambique
Australia and New Zealand
Namibia
Central and South American Countries
Seychelles
European Countries
Swaziland
North American Countries
Tanzania
Other and rest of Oceania
Afrikaans
Sesotho
Home language
English
Setswana
isiNdebele
siSwati
(Predominantly used home
isiXhosa
South African Sign Language
language if more than one)
isiZulu
Tshivenda
Sepedi
Xitsonga
Other Please specify:
SA Citizen
Resident status
SA Permanent Resident
Dual (SA plus other)
Please specify other:
Other
Please specify:
Employed
Socioeconomic status
Unemployed – looking for work
Not working – not looking for work
Not working – housewife / homemaker
Not working – scholar / full time student
Not working – pensioner / retired person
Not working – disabled person
Not working – not wishing to work
Not working – none of the above
None
Disability status
Sight
(experience problems even when wearing glasses / contact lenses)
(experience problems even when wearing hearing aid or with implant)
Hearing
(If necessary, please select
Communication
(talking / listening)
more than one item under
Physical
(moving / standing / grasping)
this section)
Intellectual
(difficulties in learning / retardation)
Emotional
(behavioural or psychological)
(not mentioned above)
Other
SANC – 10.16 (2014-07-30)

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