SECTION A: PERSONAL DETAILS

MODE OF ENTRY
PROGRAMME TYPE
userid
PASSPORT PHOTO
COURSE OF STUDY - 2nd Choice
COURSE OF STUDY - 1st Choice
PREFERRED MODE OF STUDY
SURNAME
FIRST NAME
MIDDLE NAME
MAILING ADDRESS
PERMANENT HOME ADDRESS
DATE OF BIRTH
PHONE NUMBER
NATIONALITY
LGA
STATE OF ORIGIN
RELIGION
DENOMINATION
GENDER
MARITAL STATUS
MAIDEN NAME (IF APPLICABLE)
FULL NAMES & MAILING ADDRESS OF SPONSORS
RELATIONSHIP
SPONSOR'S PHONE NUMBER
HOW DID YOU HEAR ABOUT US?
NAME OF REFERRAL
REFERRAL PHONE NUMBER
REFERRAL EMAIL ADDRESS

SECTION B: ACADEMIC RECORDS

Institutions attended, with dates (including Universities)
NAME OF INSTITUTION
LOCATION
PERIOD
QUALIFICATION OBTAINED
NAME OF INSTITUTION
LOCATION
PERIOD
QUALIFICTION OBTAINED
NAME OF INSTITUTION
LOCATION
PERIOD
QUALIFICATION OBTAINED
NAME OF INSTITUTION
PERIOD
LOCATION
QUALIFICATION OBTAINED
Examinations taken with results
EXAM TYPE
EXAM DATE
EXAM CENTRE
EXAM NUMBER
Grade in English Language
Grade in Mathematics
Subject 3
Grade
Subject 4
Grade
Subject 5
Grade
JAMB REGISTRATION NO
YEAR OF EXAM (JAMB)
JAMB EXAM TYPE
Session

SECTION C: DECLARATION

DECLARATION
I solemnly declare that all the information provided by me above is correct and true. I therefore, accept responsibility for any inaccuracies and or falsification which Ajayi Crowther University Senate may discover and consider grave enough to lead to the termination of my studentship at any time during my stay in the University or even to the withdrawal of any degree awarded based on the information. I also promise to abide by all rules and regulations, including the payment of all prescribed fees.