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
