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YELWA COLLEGE OF MEDICAL SCIENCE

Rijau Local Government Area, Rijau, Niger State

APPLICATION FORM

PERSONAL INFORMATION

FORM NO: 289379

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SURNAME:

FIRST NAME:

MIDDLE NAME:

DOB:

GENDER:

STATE OF ORIGIN:

LGA

REGILION:

PHONE NUMBER:

EMAIL:

Personal Address

COURSE SELCTION

FIRST CHOICE

SECOND CHOICE

ADMISION INFORMATION (ADMITTED STUDENT ONLY)

CURRENT LEVEL

YEAR OF ADMISSION

CURRENT DEPARTMENT

ADMISSION NO

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NAME:

ADDRESS:

PHONE NUMBER:

RELATIONSHIP:

PRIMARY SCHCOOL ATTENDED

NAME OF SCHOOL:

SCHOOL ADDRESS:

YEAR OF GRADUATION

SECONDARY SCHOOL ATTENDED

NAME OF SCHOOL:

SCHOOL ADDRESS:

YEAR OF GRADUATION

TERTIARY INSITUTION ATTENDED

NAME OF SCHOOL:

SCHOOL ADDRESS:

CERTIFICATE OBTAINED

YEAR OF GRADUATION

SSCE RESULT

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FIRST SEATING SSCE RESULT

EXAMINATION TYPE

EXAMINATION YEAR

EXAM NUMBER

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SECOND SEATING SSCE RESULT

EXAMINATION TYPE

EXAMINATION YEAR

EXAM NUMBER

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I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”

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Student Signature

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Date

PAYMENT CLEARANCE

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Bursary Signatuere & Stamp

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Date

YELWA COLLEGE OF MEDICAL SCIENCE

APPLICATION FORM

PERSONAL INFORMATION

COURSE SELCTION

ADMISION INFORMATION (ADMITTED STUDENT ONLY)

NEXT OF KIN

PRIMARY SCHCOOL ATTENDED

SECONDARY SCHOOL ATTENDED

TERTIARY INSITUTION ATTENDED

SSCE RESULT

Seating

FIRST SEATING SSCE RESULT

SECOND SEATING SSCE RESULT

Application form