MARCH 2006 DIET ATS EXAMINATION APPLICATION FORM
Bank: <== Where payment was made
Bank Branch: Teller No.:
Payment Date: Amount Paid:
Student Reg. No. Stud. Reg. Date: 
Surname: FirstName:
MidName: Title:
E-Mail Add:  Tel/GSM No.:
Postal Address:
Please state correctly the examination centre, level and subjects being applied for below
EXAM Centre:  
Exam Level    
Please state correctly Qualification(s) obtained below
Qualification: Discipline:
School: Year Qualified:
Please state if you were granted exemption by ICAN and when last you took ICAN exams
Granted Exemption: Date Granted:  
Year of Last Exam: Last Exam No.: