APPLICATION REQUIREMENTS

APPLICATION REQUIREMENTS

MODEL POLYTECHNIC NO. 2716 JEBBU BASSA, PLATEAU STATE NIGERIA

APPLICATION FORM FOR ADMISSION INTO THE ACADEMIC PROGRAMMES

APPLICATION NO

Study the GUIDELINES FOR ADMISSION INTO ACADEMIC programmes first before completing this APPLICATION FORM. The original and photocopy of the completed APPLICATION FORM should be returned to the REGISTRAR (ADMISSIONS). MODEL POLYTECHNIC with the following

Passport size photocopy of applicant must be attached here your name should be written at the back of the photocopy

1. A photocopy of the receipt for the purchase of the form 2. 2 No. Passport photographs 3. Two clear copies of credentials

SECTION A: PROGRAMME OF STUDENT___________________________________________________ DEPARTMENT ______________________________________________________________ SCHOOL ___________________________________________________________________ NATURE of programme: Regular/ (morning) or part- time (evening) DURATION OF COURSE/PROGRAMME ____________________ SECTION B: PERSONAL DATA

(a) Name (in capital) ____________________________________________________________

(Surname First) (Other names) (b) Date of Birth: ______________________© Place of Birth: ____________________________ (d) Sex _____________________________(e) Nationality: ______________________________ (f) State of Origin: _____________________(g) Home Town _____________________________ (h) L.G A. _________________________________ (I) Permanent Home Address _____________________________________________________ ____________________________________________________________________________ (j) Current Contact/Postal Address _________________________________________________ (k) Residential Address __________________________________________________________ (l) Name and Residential Address of Parent/Guardian __________________________________ ___________________________________________________________________________ (m) Occupation _________________________________________________________________

NOTE: Please inform The Registrar of any change in your contact/postal address

SECTION C: INSTITUTION(S) ATTENDED

S/NO. NAME OF INSTITUTIONS FROM TO

(I) (ii) (iii) ( iv )

SECTION D: EDUCATIONAL QUALIFICATIONS (List of the best 4,5 or 6 subjects as applicable qualifying you for the chosen programme. Attach photocopies of credential of results of qualifying exams already taken. If results are awaited, mark “ R,A” against the subjects on the Grade column)

(A) SSCE/NECO/TC11/NABTEB (B) OTHERS (SPECIFY)............................

SUBJECTS GRADE DATE CENTRE

© OTHERS CERTIFICATES

Please specify e.g. Poly cert., RSA Stage 11, Pitman etc) (I) ____________________________________________ (ii) ____________________________________________ (iii) ____________________________________________ Date obtained ___________________________________ Name of Institution _______________________________ (a) Name of Sponsor _____________________________ (b) Designation (official Status) _____________________ © Name and address of Sponsoring Company/Organization ________________________ _________________________________________________________________________ (d) Signature of Representative of sponsoring Organization

(Affix seal and Date) (e) Candidate’s Phone No: ___________________________________________________

SECTION E: DECLARATION (By Candidates): (I hereby declare that the information given in this form is to the best of my knowledge and they are correct).

Signature of Candidate ____________________ Date _________________

Receipt No. FOR OFFICIAL USE

Date:

Q/No/AR:

Signature of checking officer

Name:

Date:

EXAM NO.

SUBJECTS

GRADE DATE CENTRE

EXAM NO.