ZAMBIAN OPEN UNIVERSITY P. O. BOX 31925 LUSAKA Application No:…………… Receipt No:……………….. Received by:……………… Date:……………………… (tick Full-time/ Part-time ) FULL-TIME PART-TIME FOR OFFICIAL USE ONLY REGISTRAR’S COMMENT: ________________________________________________ ________________________________________________ ________________________________________________ APPLICATION FOR ADMISSION TO DEGREE, DIPLOMA OR CERTIFICATE PROGRAMMES PROGRAMMES AVAILABLE (tick programme applied for) Bachelor of Education B.Ed Secondary B.Ed Early Childhood Education Bachelor of Laws (LL.B) Bachelor of Arts in Policing and Security Studies Bachelor of Arts with Development Studies (BA Development Studies) Bachelor of Business Administration Bachelor of Business in Human Resource Management Bachelor of Business in Accounting Bachelor of Business in Banking and Finance Bachelor’s Degree in Marketing Bachelor’s Degree in Public Relations Bachelor of Science in Financial Mathematics and Statistics Bachelor of Science ( Agribusiness Management) Bachelor of Science ( Agricultural Economics) Bachelor of Arts in Governance and Public Administration Diploma in Early Childhood Education Diploma in Civic Education Diploma in Policing and Security Studies 2 FULL NAME (Surname, Middle name, First name) Surname Other names 3 5 6 7 8 SEX Male - M Female - F DATE OF BIRTH 4. D D MARITAL STATUS M M Y Married Unmarried Divorced Y NATIONALITY NATIONAL REGISTRATION CARD NO. PASSPORT NO: ____________________________________ POSTAL ADDRESS 9 10 RESIDENTIAL ADDRESS TELEPHONE NUMBER(S): Work:___________________________________ Residential:___________________________________ E-mail:___________________________________ 11 LAST SECONDARY SCHOOL/ INSTITUTION ATTENDED (give dates) ___________________________________________________________________________ _______________________________________________________________ 12 “O” LEVEL OR EQUIVALENT EXAMINATION PASSED AND GRADES ATTAINED IN EACH SUBJECT SUBJECTS GRADES NAME OF EXAMINATION _______________________ ______________________________ _______________________ ______________________________ _______________________ ______________________________ _______________________ ______________________________ _______________________ ______________________________ _______________________ ______________________________ _______________________ ______________________________ _______________________ ______________________________ Please enclose copy/ies of statement of results or/and certificate/s 13 ANY OTHER QUALIFICATIONS OBTAINED i. Degree/s _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 14 ii. Diploma/s _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ iii. Certificate/s _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ IF YOU HAVE BEEN PREVIOUSLY ENROLLED AS A STUDENT AT ZAOU INDICATE YOUR STUDENT NUMBER:------------------------------------------------ 15 ___________________________________________________________ ARE YOU CURRENTLY ENGAGED IN ANY STUDIES? Yes/No:____________________________________________________________________ ___________________________________________________________________________ _________________________________________________________ (if ‘Yes’, state the nature and type of studies and qualification sought, including examining body). 16 DO YOU HAVE ANY PHYSICAL OR COMMUNICATION DISABILITY? a. circle 1. Vision 2. Mobility 3. Speech 4. Hearing 5. Others b. if any of the above give details of disability_________________________ ____________________________________________________________ ____________________________________________________________ 17 ARE YOU: a. b. c. A child of a Member of Staff A Member of Staff A spouse of a Member of Staff 18 FILL THIS PART IF YOU ARE PRESENTLY EMPLOYED iv. Type of Employment or Job:______________________________________ v. Name of Employer:_____________________________________________ vi. Address of Employer:___________________________________________ vii. Period of Service:_____________________________________________ 19 NAME ADDRESS AND PHONE NUMBER OF NEXT OF KIN:_________________________________ ___________________________________________________________________________ ___________________________________________________________________________ _______________________________________________________ 20 RELATIONSHIP______________________________________________________ 21 SPONSORSHIP FOR STUDY i. Self (tick)__________________________ ii. Other (state)________________________ 22 SIGNATURE OF APPLICANT:_______________________ DATE:______________