Short Courses Application Form - United States International

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UNITED STATES INTERNATIONAL UNIVERSITY - AFRICA
Center for Executive and Entrepreneurial Development
APPLICATION FORM
PLEASE PRINT CLEARLY
1. PERSONAL INFORMATION
Mr/Ms/Dr./Prof
Last Name
First Name
Other Names
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enter text.
Street Address P.O. Box Number: Click here to enter text.
City State: Click here to enter text. Zip/Postal Country: Click here to enter text.
Daytime Phone Evening Phone Fax Number: Click here to enter text.
Mobile Number: Click here to enter text.
E-mail:Click here to enter text.
Date of Birth Click here to enter text.Place of Birth: Click here to enter text.
Citizenship: Click here to enter text. Marital Status: Click here to enter text.
National ID No.Click here to enter text.
Female: Click here to enter text.Male: Click here to enter text.
Next of Kin or Guardian (Contact in case of emergency) Click here to enter text.
Current Mailing Address (if different from above)Click here to enter text.
Are you a permanent Kenyan resident or citizen? YES Click here to enter text.| NO Click here to enter text.

If YES, provide a copy of this status together with the Application.Click here to enter text.
2. ENROLLMENT INFORMATION
Please check the Programme you are enrolling for:
1. CEED Women Entrepreneurs Certificate Program ☐
2. Short Course ☐
3. Executive Diploma in Industrial Relation☐
Course
Fee (Kshs)
Duration
Dates
P. O. Box 14634- 00800 Nairobi, Kenya. Phone: 254-20-3606000, 3606 129.Cell: 0735661704, 0719513529
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enter text.
WORK EXPERIENCE (CURRENT)
Name of Business Click
here to enter text.
Industry or Sector of the business Click here to enter text.
How long has the business been in existence? Click here to enter text.
Indicate your position in the business Click
here to enter text.
EDUCATION
PLEASE LIST ALL SCHOOLS AND COLLEGES ATTENDED IN THE FOLLOWING SECTION
NAME OF
SCHOOL/COLLEGE/
UNIVERSITY
City/country
Years (from – to)
Area of
Study
Name of
Certificate
How did you learn about USIU? –
School Teacher ☐Other (specify) ☐Friend ☐Newspaper ☐T.V. ☐Radio☐Mailing ☐College/High School Fair
☐USIU Website ☐
ATTESTATION
I hereby certify that the information given in this application is correct and complete to the best of my knowledge,
and hereby give my permission to the Admissions Office to obtain any verification deemed necessary to process my
application.
I further certify that I will arrange for the forwarding of official transcripts as requested in the instructions and that
such transcripts become the property of the university and will neither be forwarded to another institution nor
returned to me. I will include with this application my application fee and other documents as required in the
application instructions.
Signature: Click here to enter text.
Date: Click here to enter text.
IT IS MANDATORY TO SIGN YOUR APPLICATION FORM BEFORE RETURNING IT T
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Registration Requirements
1.
2.
3.
4.
5.
Academic Testimonials
Professional certificates
A one page written statement explaining the reasons for enrolling in the programme
Passport size photograph
Non-refundable application fee of Kshs. 1000
*Note: No cash payments are accepted in the finance office
All payments should be made by bankers cheques issued to United States International University (USIU), or
deposited into the accounts below; (then forward the deposit slip to the Finance Office at USIU).
USIU-AFRICA ACCOUNTS:
1. Commercial Bank of Africa Ltd.
Wabera Street Branch, Nairobi
Current Account No. 0102678001
Foreign Account No.0151874002
(Dollar account only)
2. Commercial Bank of Africa Ltd.
Upper Hill Branch
KShs Account Number: 6438840014
Account Name: USIU or U.S. International University
SWIFT Code: CBAFKENX
3. Standard Chartered Bank
Kenyatta Avenue Branch, Nairobi
A/c No. 0104023439700
4. The Co-operative Bank of Kenya Ltd.
Co-op. Bank House Branch, Haile Selassie Av, Nairobi
Current Account No. 011/20/021341/00
5. MPESA Details
Lipa Na MPESA >> Pay bill >> Business Number: 516900
Account Number : [CEED-Your Name]
Amount: KShs……………
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SURVEY (OPTIONAL)
In order for us to provide you with your exact training and improve our course listing, please
answer the questions below:
1. List other course(s) you would like to take with usClick here to enter text.
2. Where would you most prefer to take our short courses from (tick those that apply)
a) At a hotel☐
b) Nairobi Central Business District☐
c) At your premise☐
d) Other (Indicate please) ☐Click here to enter text.
3. Please indicate your thoughts about our charges (tick one)
a) Good ☐ b) Moderate☐
c) Poor ☐
d) Other (List please)☐
Click here to enter text.
4. Please rate the duration/number of hours allocated to the course (Tick one)
a) Sufficient☐
b) Not sure☐ c) Not Sufficient☐ d) Other (Specify)☐Click here
to enter text.
Thank you for your participation
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