SECTION A: PERSONAL DETAILS

MODE OF ENTRY
COURSE OF STUDY - 1st Choice
COURSE OF STUDY - 2nd Choice
PASSPORT PHOTOGRAPH
SURNAME
FIRST NAME
SECOND NAME
CONTACT ADDRESS
PERMANENT HOME ADDRESS
GSM PHONE NUMBER
DATE OF BIRTH
GENDER
NATIONALITY
STATE OF ORIGIN
LGA
RELIGION
DENOMINATION
MARITAL STATUS
MAIDEN NAME (IF APPLICABLE)
FULL NAMES OF PARENTS/GUARDIAN
CONTACT ADDRESS
EMAIL ADDRESS
RELATIONSHIP
FATHER/GUARDIAN'S GSM NO
MOTHER'S GSM NO
DETAILS OF PERSON RESPONSIBLE FOR YOUR FEES
NAME
RELATIONSHIP
CONTACT ADDRESS
TELEPHONE NUMBER
EMAIL ADDRESS
ARE YOU ON SCHOLARSHIP?
IF YES, GIVE DETAILS
ANY HEALTH OR PHYSICAL CHALLENGE?
IF YES, GIVE DETAILS

SECTION B: ACADEMIC RECORDS

Institutions attended, with dates (including Universities)
NAME OF INSTITUTION
LOCATION
PERIOD
QUALIFICATION OBTAINED
NAME OF INSTITUTION
LOCATION
PERIOD
QUALIFICTION OBTAINED
NAME OF INSTITUTION
LOCATION
PERIOD
QUALIFICATION OBTAINED
NAME OF INSTITUTION
LOCATION
PERIOD
QUALIFICATION OBTAINED
EXAMINATIONS TAKEN WITH RESULTS
EXAM TYPE
EXAM DATE
EXAM CENTRE
EXAM NUMBER
Grade in English Language
Grade in Mathematics
Subject 3
Grade
Subject 4
Grade
Subject 5
Grade
CURRENT JAMB DETAILS
UTME
REGISTRATION NUMBER
YEAR OF EXAM
1. JAMB Subject
Score
2. JAMB Subject
Score
3. JAMB Subject
Score
4. JAMB Subject
Score
TOTAL SCORE
UPLOAD JAMB RESULT
DIRECT ENTRY
DE EXAM TYPE
Session
REGISTRATION NUMBER
YEAR OF EXAMINATION
UPLOAD RESULT

SECTION C: DECLARATION & REFERRAL

DECLARATION
I solemnly declare that all the information provided by me above is correct and true. I therefore, accept responsibility for any inaccuracies and or falsification which Ajayi Crowther University Senate may discover and consider grave enough to lead to the termination of my studentship at any time during my stay in the University or even to the withdrawal of any degree awarded based on the information. I also promise to abide by all rules and regulations, including the payment of all prescribed fees.

PLEASE PROVIDE REFERRAL DETAILS

Who introduced the University to you?
Name
Address
Email Address
Phone Number