Pebble Hills University USA -Application Form.
PERSONAL DETAILS
Surname/Family Name:
First/given names:
Previous surname/Family name (if applicable)
Title (Dr, Mr., Mrs., Ms, Miss, etc):
Date of birth:
Sex (male or female)
Country of birth
Country of permanent residence:
Present Nationality
ADDRESSES
Permanent home address:
Address for Correspondence (if different from home address)
Postal Code:
Postal Code:
Tel:
Tel:
Fax:
Fax:
Email:
Email:
PROGRAM OF STUDY
Level and Discipline of Program:
Major 1: _____________________________
Dip BA BSc BS MA MEd MSc MPhil
Major 2 (if any): _______________________
Taught Doctorate PhD Other __________________________
Minor 1 (if any): _______________________
Commencing in ____________________ (year)
Minor 2 (if any): _______________________
RESEARCH
Proposed start date: Jan Feb
Mar Apr
May
June
METHOD OF STUDY
July Aug
Sep Oct Nov
Dec
UNIVERSITY STAFF MEMBERS ONLY
Full time
Please indicate whether you are applying for the discount of
Part time
part time fees
Distance Learning
YES
NO
FOR OFFICIAL USE ONLY
Decision: Accept Reject Waiting for Documents
Faculty:
Supervisor(s)
Department:
Field of Study:
Start Date:
Person-in-charge Signature:
1
Pebble Hills University USA
113 Barksdale Professional Center, City of Newark, County of New Castle, Zip Code 19711, USA. www.pebblehills.edu / www.elakgroup.com
ELAK Academy…PHU Distance Learning Center Nigeria
EDUCATION AND QUALIFICATION
Name of Institution / Address
Dates (month-year)
Qualification/award (include class &
of attendance
Main subjects
division or grade obtained)
From
To
From
To
From
To
From
To
From
To
NB: Photocopies of all certificates, certificates and course transcripts awarded for these qualifications must be enclosed with this application.
ENGLISH LANGUAGE
Surname/Family Name:
First/given names:
Previous surname/Family name (if applicable)
Title (Dr, Mr., Mrs., Ms, Miss, etc):
Date of birth:
Sex (male or female)
Country of birth
Country of permanent residence:
Present Nationality
ADDRESSES
Permanent home address:
Address for Correspondence (if different from home address)
Postal Code:
Postal Code:
Tel:
Tel:
Fax:
Fax:
Email:
Email:
PROGRAM OF STUDY
Level and Discipline of Program:
Major 1: _____________________________
Dip BA BSc BS MA MEd MSc MPhil
Major 2 (if any): _______________________
Taught Doctorate PhD Other __________________________
Minor 1 (if any): _______________________
Commencing in ____________________ (year)
Minor 2 (if any): _______________________
RESEARCH
Proposed start date: Jan Feb
Mar Apr
May
June
METHOD OF STUDY
July Aug
Sep Oct Nov
Dec
UNIVERSITY STAFF MEMBERS ONLY
Full time
Please indicate whether you are applying for the discount of
Part time
part time fees
Distance Learning
YES
NO
FOR OFFICIAL USE ONLY
Decision: Accept Reject Waiting for Documents
Faculty:
Supervisor(s)
Department:
Field of Study:
Start Date:
Person-in-charge Signature:
1
Pebble Hills University USA
113 Barksdale Professional Center, City of Newark, County of New Castle, Zip Code 19711, USA. www.pebblehills.edu / www.elakgroup.com
ELAK Academy…PHU Distance Learning Center Nigeria
EDUCATION AND QUALIFICATION
Name of Institution / Address
Dates (month-year)
Qualification/award (include class &
of attendance
Main subjects
division or grade obtained)
From
To
From
To
From
To
From
To
From
To
NB: Photocopies of all certificates, certificates and course transcripts awarded for these qualifications must be enclosed with this application.
ENGLISH LANGUAGE