You are on page 1of 4

EXCELSIOR COMMUNITY COLLEGE

STUDENT APPLICATION FORM ACADEM IC YEAR 20______to 20______


SHOULD WRITE CAREFULLY IN INK USING BLOCK CAPITALS. No:

PLEASE READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM. YOU PERSONAL DATA
1. SURNAM E 2. FIRST NAM E

3.

M IDDLE NAM E (S)

4.

M ARITAL STATUS Tick the appropriate box: Singl e Divorced W idow ed

5.

M AIDEN SURNAM E [Fami l y name at birth]

M arried Gender M F

6.

AGE

7.

DATE OF BIRTH
DD MM YY

8.

NATIONALITY

9.

TAX REGISTRATION NUM BER (TRN)

10. PERM ANENT ADDRESS NUM BER & STREET NAM E (DISTRICT)

TOW N/CITY/PARISH

COUNTRY

E-M AIL ADDRESS

TELEPHONE NUM BERS

HOME:

W ORK:

CELL:

11. ADDRESS W HILE AT COLLEGE (If different from above) NUM BER & STREET NAM E

TOW N/CITY/PARISH

COUNTRY

TELEPHONE NUM BERS

HOME:
12. NEXT OF KIN

W ORK:

CELL:
RELATIONSHIP

NUM BER & STREET NAM E (DISTRICT)

TOW N/CITY/PARISH

COUNTRY

TELEPHONE NUM BERS HOM E: W ORK: 13. PROGRAM M E TO W HICH APPLICATION IS M ADE: Department Programme M odul e Intended l ength of stay at this Institution: __________________ Year(s) 14. Have you appl ied before?15. W ere you previousl y a student at this Col l ege? Yes [ Yes [ ] No [ ] If YES: State Dept.: Course: ] CELL: M ODE OF STUDY: Ful l Tim e Day Rel ease Part Time W eek-End No [ ] I.D. No.:

SIGNATURE OF APPLICANT:

DATE:

LIST THE NAMES OF THE INSTITUTIONS YOU HAVE ATTENDED: INSTITUTION (S) : DATE (S) :

GIVE THE NAMES AND ADDRESSES OF TWO REFERENCES ONE OF WHOM SHOULD BE FROM THE LAST SCHOOL OR COLLEGE YOU ATTENDED. NOTE: TWO WRITTEN RECOMMENDATIONS MUST ALSO ACCOMPANY THIS FORM. NAME:

ADDRESS: TELEPHONE: NAME: (h) (w) (cell)

ADDRESS: TELEPHONE: (h) (w) (cell)

EXAMINATION RECORD: COPIES SHOULD BE SUBMITTED WITH THIS FORM. ORIGINAL DOCUMENTS MUST BE SUBMITTED
AT THE INTERVIEW.

RESULTS KNOWN
SUBJECT (S) LEVEL YEAR RESULT SUBJECT (S)

RESULTS AWAITING
LEVEL YEAR RESULT

RELIGION/DENOMINATION: ________________________________________________________________________________________________________ INTENDED CAREER: INDICATE THE COURSE (S)/SUBJECT (S) YOU WISH TO PURSUE:

EXTRA CURRICULAR ACTIVITIES:

ACHIEVEMENTS:

WORK EXPERIENCE: COMPANYS NAME: DEPARTMENT: TYPE OF JOB: CONTACT PERSON: COMPANYS NAME: DEPARTMENT: TYPE OF JOB: CONTACT PERSON:

FINANCE

STUDENTS LOAN

SCHOLARSHIP: x SPECIFY

SPONSOR: x x GOVERNMENT: PRIVATE: SPECIFY SPECIFY

NATIONAL YOUTH SERVICE

SELF

OTHER (PLEASE SPECIFY)

FOR PARENTS/GUARDIAN/NEXT OF KIN


THIS CERTIFIES THAT I AM PARTIALLY / WHOLLY RESPONSIBLE FOR

WHILE HE/SHE IS ATTENDING THE COLLEGE AND WILL BE FINANCIALLY RESPONSIBLE FOR HIS/HER EXPENSES.

PRINT NAME

RELATIONSHIP

SIGNATURE

DATE

COMPLETE THIS FORM AND RETURN IT TO THE STUDENTS AFFAIRS OFFICE ALONG WITH DOCUMENTS BELOW. FOR OFFICE USE ONLY
RECEIVED
ORIGINAL & ONE (1) COPY OF EXAMINATION RESULTS ORIGINAL & ONE (1) COPY OF BIRTH CERTIFICATE ORIGINAL & ONE (1) COPY OF MARRIAGE CERTIFICATE AND DEED POLL (WHERE APPLICABLE) TWO PASSPORT SIZE PICTURES (NAME, DEPARTMENT & YEAR WRITTEN ON BACK) TWO CHARACTER REFERENCES (ONE FROM THE LAST SCHOOL ATTENDED/ EMPLOYER & THE OTHER FROM A MINISTER OF RELIGION OR
JUSTICE OF THE PEACE)

APPLICATION FEE $

(APPLICATION FEE IS NON-REFUNDABLE)

STUDENTS AFFAIRS PERSONNEL SIGNATURE

DATE

FOR INTERVIEWERS USE ONLY ASSESSMENT:


APPEARANCE AWARENESS ORAL EXPRESSION MOTIVATION GENERAL SUITABILITY COMPORTMENT ASSESSMENT RATING A: EXCELLENT B: GOOD C: SATISFACTORY D: POOR

COMMENTS..

RECOMMENDATIONS..

ADDITIONAL SUBJECTS NEEDED FOR MATRICULATION.

INTERVIEWED BY [PRINT NAME]

DATE

REGISTRARS SIGNATURE

DATE

WHERE APPLICABLE:

I start of the next academic year.

agree to meet the full requirements for matriculation before the

NAME

SIGNATURE

DATE

You might also like