www.mmrewrite.co.

za

MOKOPANE MATRIC RE-WRITE CENTRE

61 BRAHMAN STREET, MOKOPANE, LIMPOPO | TEL: 015 004 2806 | CELL: 066 220 4507
PO BOX 1824, MOKOPANE, 0600 | FAX: 086 718 4261 | E-MAIL: mmrewrite@gmail.com
BANKING DETAILS: NEDBANK (Cheque), Branch: Mokopane, Acc No: 1064887090, Reference: Student Surname and Full Names
APPLICATION FOR ADMISSION
1. Student Details ID PHOTO

Surname: ______________________________ Full Names: _______________________

Preferred Name: (Must Appear on your ID) ____________________________
ID Number: _______________________ Gender:  Male  Female
Cell No:______ __________ E-mail Address: ___________________________________
Citizenship: _________________ Home Language: ______________________________ __________________
Race:  Asian  Africa  Coloured  Indian  White Year applied for:
2 0 2
T-Shirt Size:  XS  S  M  L  XL  XXL  XXXL
Last School Attended: ______________________________________ Year: _______ OFFICE USE ONLY
Any Sicknesses? (If any please explain): ______________________________________________________________________
Examination Number: (On your statement of the last time you sat as a full time matric student) ___________________________
How did you know about MMR?  Facebook  Poster in a Taxi  MMR Visited your Previous School
 MMR Staff Member  Previous MMR Student  Other (Specify) ___________________________________________

Student Signature: ____________________ Date: ________________

2. In case of an emergency who should the centre contact? (In case the person in Section 8 / 9 is not available)

Name & Surname: ___________________________________ ID Number: _____________________________

Relationship to Student: _______________________________ (Specify) Cell No: ______ __________

3. Programmes

 Amended (May / June Examinations) – 6 Months Contract. (January – June) R _____________ p/annum.
(NOTE: All fees must be paid in full by the 3rd of May in order to receive your final examination time table)
 Supplementary (May / June Examinations) – 6 Months Contract. (January – June) R _____________ p/annum.
(NOTE: Admission for supplementary does not mean you will be registered for the Oct / Nov examinations if not selected.)
(NOTE: All fees must be paid in full by the 3rd of May in order to receive your final examination time table)
 MEO (May / June Examinations) – 6 Months Contract. (January – June) R _____________ p/annum.
(NOTE: Admission for MEO does not mean you will be registered for the Oct / Nov examinations if not selected.)
(NOTE: All fees must be paid in full by the 3rd of May in order to receive your final examination time table)
 Repeat / Upgrade (Oct / Nov Examinations) – 11 Months Contract. (January – November) R _____________ p/annum.
(NOTE: All fees must be paid in full by the 3rd of October in order to receive your final examination time table)

Account Payer Signature: ____________________ Date: ________________

Student Signature: ____________________ Date: ________________

4. Fees
 1 Subject: R350 p/m
 2 Subjects: R650 p/m
 3 Subjects: R950 p/m
 4 Subjects: R1250 p/m
 5 Subjects: R1550 p/m
6 Subjects: R1850 p/m
Registration Fee: R700 (Once-Off)
PAYMENTS ONCE MADE ARE NON-REFUNDABLE (UNDER NO CIRCUMSTANCES)
Page 1 of 4 Signature of Person Responsible for the Account: _______________ Date: _______________
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5. Subject Choices
Minimum of 1 Subject and maximum of 6 Subjects to be ticked below:
- Accounting  - Mathematical Literacy  - Sepedi HL 
- Agricultural Sciences  - Mathematics  - ¹CAT 
- Business Studies  - Physical Sciences  ¹(Computer Applications Technology)
- Economics  - Afrikaans FAL  - *Electrical Technology 
- Geography  - English FAL  - *Technical Mathematics 
- History  - English HL  - *Technical Science 
- Life Sciences  - Sepedi FAL  - *Tourism 
- Other Subjects not on the list: _____________________________ *Not applicable for Amended Programme
I hereby confirm that the above selected subjects are the ones I am going to attend (Monday – Friday) and write for my final
examination.
Parent / Guardian Signature: _______________ Date: ________________
Student Signature: _______________ Date: ________________

6. Boarding Option
Boarding Fee: R 2000.00 p/m
 6 Months R _____________ p/m. R _____________ p/annum.
(NOTE: All fees must be paid in full by the 3rd of May in order to receive your final examination time table)
 11 Months R _____________ p/m. R _____________ p/annum.
(NOTE: All fees must be paid in full by the 3rd of October in order to receive your final examination time table)
Account Payer Signature: ____________________ Date: ________________
Student Signature: ____________________ Date: ________________

7. Consent and Indemnity by Student and Parent / Guardian

I, _______________________ (Parent / Guardian Surname & Name) ID number _______________________ hereby give my
consent for ______________________ (Student Surname & name), ID number _______________________, referred to on
section 1 of this document to take part in any & all extra-curricular activities of the centre as advised to myself, and also all or
any extra mural activities, including but not limited to winter school, games, athletics, tours & excursions of general, vocational,
educational, historical, geographical or scientific interest, whether free or may have additional costs & also whether conducted
on the centres’ premises or not.
I fully understand and accept that all such activities shall be undertaken at own risk and undertaken on behalf of myself, my
spouse, my executors and my student to indemnify, hold harmless and absolve the centre, the director, the management and
his/ her staff members against the following:
- Damage or loss of any personal property of the student.
- Injury or bodily harm of the student.
I agree that no claim can be made against any party connected to the centre or the centre itself in regard to conditions stated
above.
I, _______________________ (Parent / Guardian) and _______________________ (Student) will abide by the rules and
regulations of Mokopane Matric Rewrite Centre, and understand that breaking the rules and regulations will result in
disciplinary action and possible deregistration from the centre.

Signed at ___________________________ (place) on the _____ (day) of _____________ (month) _________ (year)

Parent / Guardian Signature: _______________ Student Signature: _______________ (if above the age of 18)

PAYMENTS ONCE MADE ARE NON-REFUNDABLE (UNDER NO CIRCUMSTANCES)

Page 2 of 4 Signature of Person Responsible for the Account: _______________ Date: _______________
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8. Person Responsible for the Account (Payments)

Title:  Mr  Mrs  Miss

Surname: ____ Full Names: _____________________
ID Number: ______________________ Cell No: _______________________ Tel No (W): ___________________
Cell No (Spouse): __________________ E-mail Address: _________________________________________________
Occupation: _____________________ Company: ___________________ Fax: _________________________
Residential Address: ________________________________ Postal Address: ________________________________
Marital Status:  Married  Never Married  Widowed  Divorced

9. Next of Kin of Person Responsible for the Account

Name & Surname: ___________________________________ ID Number: _____________________________

Relationship to Student: _______________________ _______ (Specify)
Cell No: ____________________________________

10. Declaration & Indemnity by the Person Responsible for the Account (Payments)
I, _______________________ (account payer) declare that I have enrolled _______________________ (student),
ID Number_______________________ at Mokopane Matric Rewrite Centre to attend the ASC/NSC examination preparation
lessons for the total of _____ subjects, and _____ months, that amounts to the total year fee of R __________ (Course) and of
R (Boarding) payable monthly.
I, the undersigned _______________________ (account payer), ID number _______________________ hereby accept that I will
be responsible for all the fees (for the programme(s) selected in section 7) mentioned in this contract. All fees are payable at the
beginning of each month, on or before the 3rd day of each month, or upon enrolment at the centre.
I declare that I bare full knowledge that the final payment must be made no later than the _______________ in order for the
student to receive his / her final examination admission letter (timetable).
I declare that I bare full knowledge that this is a fixed term contract and that should I withdraw the student from centre before
the end of the contract date, I shall still be held liable for the full payment of the said contract term payable on time monthly in
full by the end date of this contract.
- Fees in arrears, with no agreement in place, will result in the student not being allowed to attend classes until all
outstanding fees are paid up to date.
- Premature withdrawal WILL NOT result in any refund of fees paid. Failing or no improvement of marks WILL NOT result
in any refund of fees paid.
- Should the student be suspended / deregistered from the centre due to absentee or disregarding the rules, I will still be
liable for the full contract fees, and NO REFUND will be given by the centre.
Please note that if fees are not up to date, the centre has the right to deny the student mentioned in this contract access to the
centre and an interest rate of 18.5% will be charged, to outstanding fees.
I, _______________________ (account payer), ID Number _______________________ have read and understood the whole
document. I also declare that I will notify the centre of any changes to my personal information etc. & that of
_______________________ (surname & name of student).

Signed at ___________________________ (place) on the _____ (day) of _____________ (month) _________ (year)

_______________________________________ _________________________
Surname and Full Names of the Account Payer Signature of Account Payer

_______________________________________ _________________________
Surname and Full Names of Student Signature of Student

_______________________________________ _________________________
Witness – Surname and Full Names as per ID Signature of the Witness

PAYMENTS ONCE MADE ARE NON-REFUNDABLE (UNDER NO CIRCUMSTANCES)

Page 3 of 4 Signature of Person Responsible for the Account: _______________ Date: _______________
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11. Office Use Only

Mokopane Matric Rewrite Centre hereby confirms that we have accepted:

- The account payer (mentioned in section 8 of this document) to be responsible for the fees of the student
(mentioned in section 1 of this document)
- The student to attend the ASC / NSC examination preparation lessons.

Date of Admission: d d m m 2 0 2 y

Application form handled by: ___________________________________________

Signature: ____________________ Date: _________________

Overseer:

Signature: Date:

REQUIRED DOCUMENTS TO BE SUBMITTED TOGETHER WITH THIS FORM:

From Student:
 x3 Certified copies of identity document
 x3 Certified copies of Grade 9, 10 or 11 school report
(Only for Amended: If you have never completed matric before.)
 x3 Certified copy of statement of results of the last time you sat as a full time student)
 x4 ID Photos (Colour)
From Person Responsible for the Account (Payments):

 Proof of residential address

 x1 Month payslip (If available)
 x1 Month bank statement (If available)
 x1 Certified Copy of ID of the person responsible for the account (Payments)
From Parent / Guardian

 x1 Certified Copy of ID of the Parent / Guardian (If not the account payer)

Banking Details:

Bank: NEDBANK
Account Holder: Thomas Roland York (Mokopane Matric Rewrite Centre)
Account Number: 1064 8870 90
Account Type: Cheque / Current Account
Branch Code: 142748
Reference: Student Surname and Full Names

PAYMENTS ONCE MADE ARE NON-REFUNDABLE (UNDER NO CIRCUMSTANCES)

Page 4 of 4 Signature of Person Responsible for the Account: _______________ Date: _______________