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Fiche Fac SJP Ek. Anglaise Version
Fiche Fac SJP Ek. Anglaise Version
I. IDENTIFICATION OF STUDENT
Status: Priest Religious Seminarian Lay Mrs Miss Mr
Name: ____________________________________ Surname: _____________________________________
Date of birth: _____________/________/_________ Nationality: __________________________________
Religion: _________________________________Email: _________________________________________
Diocese or Congregation (For priests and religious): _____________________________________________
Employer: (For workers) ___________________________________________________________________
External: mini-city/street_______________________________ Internal: Room No ____________________
Tel.:________________Student__________________________Parent/Sponsor_______________________
II. ADMISSION
Faculty: ________ Level: ____________ Cycle: __________________Option: ________________________
Regular Adjourned Regular with re-sits Adjourned with re-sits Repeater
Repeater with re-sits
Fee: _______________ Scholarship: Yes No Nature: __________________________________
Last ______________________ class ______________________ attended:___________________________
_______________________
Signature of Dean/Director
III. INDEMNIFICATION
SCHOLARSHIP Yes No Nature ___________________________________________________
Date of medical check-up: ______/_____________/20________________________Code _______________
IV. VALIDATION OF PAYMENTS (Administration Only)
DESCRIPTION AMOUNT DATE VISA PENALTIES
Registration (non-refundable) _______________CFA --/--/20-- Registration
Students’ Associations 5000 --/--/20--
Medical check-up 4000/3.500 --/--/20-- ____________
Health Insurance 29.850 --/--/20--
1st payment ________________ --/--/20-- 1st installment
2nd payment _________________ --/--/20-- ___________
3rd payment ________________ --/--/20--
4th payment ________________ --/--/20-- 2nd installment
NB: This form must be returned to the Registrar’s secretariat immediately after validation at the bursary.
Any student who wishes to be reimbursed can only receive partial reimbursement after the Dean’s/Director’s signature.