one
photograph
to be
attached
APPLICATION FORM
<<>><<>><<>> SECTION A – PERSONAL DATA <<>><<>><<>>
SURNAME MIDDLE NAME
CHRISTIAN NAME SEX MALE FEMALE
ALSO KNOWN AS
DATE OF BIRTH (DD/MM/YY)
ADDRESS
TELEPHONE # PARISH
FAX # RELIGION
E-MAIL MARITAL STATUS Widowed Married
Divorced Single
OTHER TELEPHONE/
CONTACT # T.R.N. #
<<>><<>><<>> SECTION B – NEXT OF KIN <<>><<>><<>>
SURNAME MIDDLE NAME
CHRISTIAN NAME RELATION
ADDRESS
TELEPHONE #
FAX #
E-MAIL
<<>><<>><<>> SECTION C – DEPENDENTS <<>><<>><<>>
SURNAME M.I. CHRISTIAN
NAME
DATE OF BIRTH (DD/MM/YY)
SURNAME M.I. CHRISTIAN
NAME
DATE OF BIRTH (DD/MM/YY)
<<>><<>><<>> SECTION D – ACADEMIC QUALIFICATIONS <<>><<>><<>>
INSTITUTION ATTENDED PERIOD ACHIEVEMENT
PLEASE BRING PROOF OF EXAMINATION PASSES WHEN SUBMITTING THIS APPLICATION FORM AND REQUEST TRANSCRIPT FROM PREVIOUS
INSTITUTION.
<<>><<>><<>> SECTION E – PROGRAMME CHOICE <<>><<>><<>>
Please indicate the course of study for which you are applying:
Part-time Full-time Online/Distance
Bachelors Degree in Information Technology
Diploma in Networking
Associate Degree in Information Technology Post Graduate Diploma in Programming &
Instructional Technology
Associate Degree in Computer Network &
Associate Degree in Web Design and Development
Security
Certificate in Geographic Information
Diploma in Software Design and Development
System (GIS)
If other, please specify: ________________________________ Institution: ________________________________
<<>><<>><<>> SECTION F – REFERRAL <<>><<>><<>>
HOW WERE YOU REFERRED TO CIT? (PLEASE TICK THE APPLICABLE CHECKBOX(ES)
Friend/Family
Newspaper
Radio
Career Fair Yes____No______(Please tick) If yes, please state which Career Fair___________________
***************Expo Yes____No____ (please tick) If yes, state which
Expo______________________________________
<<>><<>><<>> SECTION F – EMPLOYMENT DETAILS <<>><<>><<>>
ARE YOU EMPLOYED? YES NO
NAME OF EMPLOYER _____________________________ ADDRESS ______________________________________
JOB TITLE ____________________________________ ______________________________________
IS YOUR PARENT/GUARDIAN/SPOUSE EMPLOYED? YES NO
NAME ________________________________________ RELATIONSHIP _________________________________
NAME OF EMPLOYER_____________________________ ADDRESS ______________________________________
JOB TITLE ___________________________________ ______________________________________
<<>><<>><<>> SECTION G – HEALTH DETAILS <<>><<>><<>>
DO YOU SUFFER FROM ANY OF THE FOLLOWING?
YES NO YES NO
ALLERGIES EPILEPSY
DIABETES ASTHMA
DEPRESSION/ MENTAL ILLNESS OTHER
If “yes”, indicate
____________________
HAVE YOU BEEN FULLY IMMUNIZED?
<<>><<>><<>> SECTION H – CRIMINAL RECORD <<>><<>><<>>
HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENCE? YES NO
IF YES, STATE DATE AND NATURE OF THE OFFENCE? ____/____/____ (DD/MM/YY)
_____________________________________________________________________________________________
I HEREBY CERTIFY THAT THE INFORMATION GIVEN BY ME ON THIS APPLICATION FORM IS TRUE, COMPLETE AND ACCURATE
TO THE BEST OF MY KNOWLEDGE.
I FURTHER UNDERSTAND THAT ANY FRAUDULENT STATEMENT WILL LEAD TO INSTANT DISMISSAL FROM THE PROGRAMME.
SIGNATURE: ___________________________________ DATE: ____/____/____ (DD/MM/YY)
<<>><<>><<>> FOR OFFICE USE ONLY <<>><<>><<>>
SELECTED NOT SELECTED
……………………………………...
APPROVED BY
