All communications should be addressed to: In reply please quote:

The Principal
Telephone: +260955370764/ 0954946766/ No.:ZCA/MP/101/3/4
+260972106913/ 0965597977
E-mail; zcampika@yahoo.com

REPUBLICOF ZAMBIA

MINISTRY OF AGRICULTURE
ZAMBIA COLLEGE OF AGRICULTURE
P.O. BOX 450143
MPIKA

Form No: ……………………………………

APPLICATION FORM FOR ADMISSION - DIPLOMA IN AGRICULTURAL EDUCATION

Applicants should complete and send the form direct to the Principal at the above address

Please use block letters

Part A

1. Surname: …………………………………………………………………………………………………………………………………….

2. Other names in full: …………………………………………………………………………………………………………………….

3. Sex: …………………….. Marital Status: ………………………………………………………………………..

4. Date of Birth: ……………………………………………………………………………………………………………………………….

5. Address where you can be contacted: ……………………………………………………………………………………….

………………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………

Contact phone/Cell Number: ………………………………………………………………………………………………………

6. Nationality: ………………………………………………………………………………………………………………………………….

7. National Registration Card (NRC) Number: ……………………………………………………………………………….

NB: Do not send originals of certificates and NRC.

Part B

Write reasons why you want to study Agricultural Education

1. …………………………………………………………………………………………………………………………………………………

2. …………………………………………………………………………………………………………………………………………………

3. …………………………………………………………………………………………………………………………………………………
Part C

(i) State the subjects which you entered and passed in senior secondary
school examinations and indicate the level of performance (NB: Attach
certified photocopies of your certificates or statement of results and
National Registration Card)

Subject Grade
1. ……………………………………………………………………………….. ……………………………………………………
2. ……………………………………………………………………………….. ……………………………………………………
3. ……………………………………………………………………………….. ……………………………………………………
4. ……………………………………………………………………………….. ……………………………………………………
5. ……………………………………………………………………………….. ……………………………………………………
6. ……………………………………………………………………………….. ……………………………………………………
7. ……………………………………………………………………………….. ……………………………………………………
8. ……………………………………………………………………………….. ……………………………………………………
9. ……………………………………………………………………………….. ……………………………………………………

(ii) Secondary Schools Attended

Name From To
…………………………………………………………………………… ………………………. ……………………………
…………………………………………………………………………… ………………………. ……………………………
…………………………………………………………………………… ………………………. ……………………………

(iii) Other qualification (Attach certified photocopies)

…………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………….

(iv) Please state if you are physically disadvantaged

…………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………….

(v) Give two names of referees and their occupation and addresses (relatives
will not be considered as references)
(a) ……………………………………………………….. (b) …………………………………………………………
……………………………………………………….. …………………………………………………………
……………………………………………………….. …………………………………………………………
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Date: …………………………………………………………… Signature: ……………………………………………………….

** The application form fee is K80.00

** Deposit into; Zambia College of Agriculture MPIKA, using ZANACO bill
musterAttach the deposit slip to the application form