AYM SHAFA SCHOLARSHIP PPLICATION FORM

A) PERSONAL INFORMATION
1. SURNAME……………………………………………………………………………………………………………..
Passport
2. FIRST NAME…………………………………………………...........................................................
3. OTHER NAME (IF ANY) ……………….............................................................................
4. DATE OF BIRTH……………………………………………………………………………………………………..
5. PLACE OF BIRTH………………………………………………………………………………………………………
6. STATE OF ORIGIN……………………………………………………………..……………………………………..
7. LGA OF ORIGIN……………………………………………………………………………..…………………………
8. PLACE OF RESIDENCE………………………………………………….………..………………………………….
9. RESIDENTIAL ADDRESS……………………………………………………………………………………………..
10. EMAIL ADDRESS……………………………………………………………………………………………………….
11. TELEPHONE NUMBER………………………………………………………………………………………………
12. PARENT’S/GUARDIAN’S OCCUPATION………………………………………….………………………….
13. NAME OF SPONSOR………..………………………………………………………….……………………………
B) ACADEMIC INFORMATION
1. UNIVERSITY………………………….………………... FACULTY……………………………………………
2. DEPARTMENT……………………………………….. COURSE OF STUDY……………………………….
3. YEAR OF ADMISSION…………………… EXPECTED YEAR OF COMPLETION………….………..
4. REGISTRATION FEES.……………………………………………………………………………………………….
C) DECLARATION BY APPLICANT
I,………………………………………………………………………………………… DECLARE THAT ALL INFORMATION
PROVIDED ABOVE IS TRUE AND ACCURATE.
___________________________ ______________________________
SIGNATURE DATE

____________________________ _______________________________
DISTRICT HEAD PARENT/GUARDIAN
(NAME AND SIGNATURE) (NAME AND SIGNATURE)

____________________________
HEAD OF DEPARTMENT (NAME AND SIGNATURE)