FICHE DE PRE-INSCRIPTION (à remplir en MAJUSCULE)

ENROLLMENT FORM (fill in CAPITAL LETTERS)

NOMS ET PRENOMS (Comme sur l’acte de naissance) : ………………………………………………………………………..

Names and surname (as on birth certificate)

……………………………………………………………………………………………………………………………………………MATRICULE:

09/4/2003
DATE ET LIEU DE NAISSANCE (JMA) : ………………………………………… TIBATI
A : …………………………………………….. SEXE : male female
Date and place of birth (DMY)
Cameroon
NATIONALITE :…………………….........................................……Tel 650463251
:…………………………………………….... / ……………………………………………
Nationality
iben51507@gmail.com
Email :………………............................................................................................................................................................
STATUT MATRIMONIAL: Marié(e) :
Marital status married
célibataire :
single
✔ Divorcé(e) :
divorced
Veuf (ve) :
widow(er)
ADAMAWA
REGION D’ORIGINE: ………………………………………………. DJEREM
DEPARTEMENT D’ORIGINE: ………………………………………………………………….
Region of origin division of origin
DIPLOME PRESENTE POUR LA PRE-INSCRIPTION :…………………………………………………………………………………………………….
Certificate presented for registration
Année d’obtention:……………………………………….Pays d’obtention:……………………………….…………………………………………....
year obtained country of issue
HONOR BILINGUAL HIGH SCHOOL COMPLEX
DERNIER ETABLISSEMENT FREQUENTE: ……………….......................................................................................................
Last school
2020
Année de sortie: ………........................................Diplôme GCE ADVANCED LEVEL
obtenu :………………………………….……….………………........
Year out Diploma
Exercez-vous une activité professionnelle? OUI NON
Are you currently employed? Yes no
Si OUI, nom et adresse de votre employeur/ entreprise: …………………………………………………………………………………………………..
If YES, name and address of your employer/enterprise
Comment connaissez-vous AZIMUT: Site web Plaque pub Prospectus Relation
How do you know about AZIMUT; web site sign board flyers relatives ✔
ANNEE ACADEMIQUE(Academic Year) 20 /20 Facebook

Capacité en Droit et en
CYCLE:
Economie (L1/L2/L3/Masters)
BTS
HND
✔ LICENCE
Bachelor’s degree
MASTER
MBA
H

Healthcare Management
Spécialité : ……………………………………………………………………………………………………………………………………………
Specialty
INSCRIPTION EN : 1ère année 2è année 3è année 4è année 5è année
Admission in first year ✔ second year third year fourth year fifth year
SESSION : cours du jour cours du soir REDOUBLANT : OUI NON
Day classes ✔ Evening classes Repeater: YES NO ✔
ADRESSE DES PARENTS OU TUTEUR / PARENTS OR GUARDIAN ADDRESS
Noms et premons (Name and surname)
DJIBRILOU BABA
Pere/ Father : ……………………………………………………………………………………………………………………………………
HAWAOU
Mere/ Mother : …………………………………………………………………………………………………………………………………
Profession (Occupation)
COMMERÇANT
Pere/ Father : ……………………………………………………………………………………………………………………………………
MÉNAGÈRE
Mere/ Mother : …………………………………………………………………………………………………………………………………
Adresse (Address)
TSINGA VILLAGE
Pere/ Father : ……………………………………………………………………………………………………………………………………
TSINGA VILLAGE
Mere/ Mother : …………………………………………………………………………………………………………………………………
Telephone
674476675
Pere/ Father : ……………………………………………………………………………………………………………………………………
653588600
Mere/ Mother : …………………………………………………………………………………………………………………………………