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INSTRUCTION:This form must be compleated in PRINTED CAPITAL LETERS.
Each application must be accompanied with photocopies of:
(i) Birth certificate/sworn declaration of age
(ii) Credentials
(iii) Certificate of origin from the Local Government Area
SECTION A: PERSONAL DATA
Title:  
Surname:  
OtherNames:  
DateOfBirth:
EMail:    
Sex:
PlaceOfBirth:
Nationality:  
StateOfOrigin:
LGA Of Origin
ResidentAddress:  
PostalAddress:
Phone:
NameAndAddress
OfNextOfKin:
RelationShip
WithNextOfKin:
SECTION B:       PROPOSED PROGRAMME OF STUDY
FIRST CHOICE:
ProgrammeOfStudy...
Department...
   

SECOND CHOICE:
ProgrammeOfStudy...
Department...
   

NATURE OF PROGRAMME:
SECTION C:          OTHER CERTIFICATES
Please specify e.g. (Polytechnic Certificate, RSA Stage II,NECO) Etc.
I
II
III
IV

SECTION D: EDUCATIONAL RECORDS
PLEASE PROVIDE THE EXAM RECORD YOU ARE INTENDING TO USE IN OBTAINING ADMISSION 
SN SUBJECT GRADE DATE OF EXAM EXAM NO EXAM TYPE
1
2
3
4
5
6
7
8
9
10
11
 
SECTION E: INSTITUTIONS ATTENDED
PLEASE PROVIDE ALL INSTITUTIONS ATTENDED
SN NAME OF INSTITUTION DATE ATTENDED
FROM TO
1
2
3
4
5
6
 
NAME OF SPONSOR:
DESIGNATION(Official Status):
NAME AND ADDR. OF SPONSORING ORG.:
SECTION D:           OTHER RELEVANT INFORMATION
WHAT ARE YOUR SOCIAL ACTIVITY:
WHAT ARE YOUR HOBBIES
SECTION E: DECLARATION BY THE CANDIDATE
I
hereby declare that the information given in this form is to the best of my knowledge correct and should be held responsible incase of any default. If admitted into the Polytechnic, I shall abide by rules and regulations governing students in this institution.
DATE:
SECTION F: REFEREE
This form can only be signed by either a clergyman, lawyer, last principal of candidate's school, Director of limited liability firm, or Public firm, attesting the integrity, honesty and sincerity of the candidate, ensuring that the candidate is not associated with cultism, vandalism or other social vices.
NAME OF REFEREE:
ADDRESS:
STATUS:

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