Quality Assurance Exit Survey
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OFFICE OF THE ACADEMIC REGISTRAR APPLICATION FOR ADMISSION TO DOCTORAL PROGRAM ACADEMIC YEAR……………..
1.0 PROGRAM APPLIED FOR:
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1.1 APPLICANT’S PERSONAL INFORMATION
Name (Use names on academic documents)
Surname:
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Other name:
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Tittle: ( Mr/Mrs/ Miss/ Rev/ Dr /Other )
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Gender
Male
Female
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Date of Birth: (DD/MM/YY)
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Nationality:
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Country of Residence:
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Home District:
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Religious Affiliation:
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Marrital Status:
Single
Married
Other
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1.2 Address:
Telephone contact:
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Email:
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Postal Address:
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Sponser's/ Guardians Name:
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Telephone Contact :
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Next of Kin:
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Telephone Contact
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1.3 Employment Record (with current or most recent institution) Designation / Period (From - To)
Name of Institution 1
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Name of Institution: 2
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Name of Institution: 3
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Name of Institution: 4
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3.0 Academic Record:
Secondary School, Colleges and Universities attended (Give names, dates, qualifications and grades).

1.
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2.
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3.
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4
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5
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6
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3.1 Other professional qualifications (with dates)
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3.2 State Research/ Publications you have undertaken.
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3.3 State briefly the reason why you want to pursue this programme and its relation toyour interest/future job responsibilities.
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Sponsership:
Name(s)Sponsor(s)
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Address of Sponsor(s)
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Telephone Contact(s)
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Declaration: ( I declare that the information filled in this form is correct)
Signiture:
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Date:
MM
/
DD
/
YYYY
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