Lead Institute

Application Form 2016/2017

This form must be completed and submitted as a word attachment via leadinstitutedm@gmail.com
or fax to 757-440-3257. Alternatively, you may mail to:
Lead Institute, P.O. Box 1091, Roseau, Commonwealth of Dominica
NB: There is a $25.00 Application Fee which must be paid before your application can be
processed. This fee is non-refundable.

Section 1: Biographical Information

Nationality:
Name:
Place of birth:
Date of birth / /
Gender Male ( ) Female ( )
Contact Address:

Home Telephone Work Telephone

Mobile Fax Number
E-mail Address

Section 2: Education Information

What is your highest level of education attained?

Primary ( ) Junior Secondary ( ) High School/GCE/CXC ( ) College ( ) University ( )
List schools attended and subjects / qualifications attained
From To Name and Address List all certificates achieved and
external exams passed with Grades

Section 3: Work Experience

What is your work experience?

Section 1: Intended Course of Study

Which program are you applying for?

( ) CXC Associate Degree ( ) Business Studies ( ) Computer Science ( ) General Studies
( ) Humanities ( ) Natural Sciences
( ) CAPE ( ) Mgmt Business ( ) Economics ( ) Accounting
( ) Caribbean Studies ( ) Communications Studies ( ) Law
( ) Information Technology ( ) Sociology ( ) Pure Mathematics
( ) Environmental Studies ( ) Entrepreneurship ( ) Geography
( ) Computer Science ( ) History ( ) Digital Media

( ) CXC CSEC ( ) Accounting ( ) Economics ( ) English

( ) Human & Social Biology ( ) Information Technology
( ) Mathematics ( ) Social Studies
How did you learn about Lead Institute? Please list name of individual and or media
( ) Friend ( ) Newspaper
( ) Radio ( ) Internet
( ) Other