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MIDLANDS STATE UNIVERSITY
P.BAG 9055
GWERU

UNDERGRADUATE ADMISSION APPLICATION

20…

N.B: First read the NOTES on the next page, then complete all sections of the form but do NOT write in the boxes which are for official use only. Print clearly in ink in the blank spaces and on the dotted lines as required. Only applications accompanied with the Headmasters report will be considered.

RETURN THE FORM BY REGISTERED MAIL/PERSONALLY
N.B. CHEQUES AND POSTAL ORDERS ARE NOT ACCEPTED.

PROGRAMME: …………………......…………....
CON/FULL TIME
(tick where appropriate)

PARALLEL

POINTS

BLOCK R./VISITING S.

BRIDGING

SURNAME:
TITLE: MR/MRS/MS/DR/MISS/REV/SR/:
FORENAMES:
MARITAL STATUS:
NATIONAL ID #

SEX

_

NATIONALITY
COUNTRY OF PERMANENT RESIDENCE
DATE OF BIRTH:
(D-M-Y)

-

-

PLACE OF BIRTH

DISABILITIES IF ANY .(Specify).................................................................................

DISABILITY CODE

…………………………………………………………………..........................................…
CONTACT ADDRESS.................................................................................................................................................................
TELEPHONE NUMBERS:

(Include country &area code)

HOME ……………………………………………………………………………….

E-MAIL …………………………………………………………… FAX ……………………………………………………...
N.B: All correspondence will be forwarded to the above address.
PROSPECTIVE SPONSORS
(e.g Self or any other organisation)...........................................................................................................................

FOR OFFICE USE ONLY
APPLICATION NO.........................................................RECEIPT NO.......................................................

1. FACULTY DEGREE PROGRAMME CHOICES
PREFERENCES:

Degree Programme

Faculty

1

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