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INSTRUCTION:This
form must be compleated in PRINTED CAPITAL LETERS.
Each application must be accompanied with photocopies of:
(i) Birth certificate/sworn declaration of age
(ii) Credentials
(iii) Certificate of origin from the Local Government Area
SECTION A: PERSONAL DATA
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Title: |
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Surname: |
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OtherNames: |
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DateOfBirth: |
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EMail: |
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Sex: |
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PlaceOfBirth: |
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Nationality: |
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StateOfOrigin: |
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LGA Of Origin |
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ResidentAddress:
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PostalAddress: |
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Phone:
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NameAndAddress
OfNextOfKin: |
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RelationShip
WithNextOfKin: |
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SECTION B: PROPOSED PROGRAMME OF STUDY
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FIRST CHOICE: |
ProgrammeOfStudy...
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Department...
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SECOND CHOICE: |
ProgrammeOfStudy...
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Department...
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NATURE OF PROGRAMME: |
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NAME OF SPONSOR: |
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DESIGNATION(Official Status): |
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NAME AND ADDR. OF SPONSORING ORG.: |
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SECTION D: OTHER RELEVANT INFORMATION |
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WHAT ARE YOUR SOCIAL ACTIVITY: |
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WHAT ARE YOUR HOBBIES |
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SECTION E: DECLARATION BY THE CANDIDATE |
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hereby declare that the information given in this form is to the best of my knowledge
correct and should be held responsible incase of any default. If admitted into the
Polytechnic, I shall abide by rules and regulations governing students in this institution. |
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DATE: |
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SECTION F: REFEREE |
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This form can only be signed by either a clergyman, lawyer, last principal of candidate's
school, Director of limited liability firm, or Public firm, attesting the integrity,
honesty and sincerity of the candidate, ensuring that the candidate is not associated
with cultism, vandalism or other social vices. |
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NAME OF REFEREE: |
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ADDRESS: |
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STATUS: |
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