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F2-59-9-1
JOMO KENYATTA UNIVERSITY OF AGRICULTURE AND TECHNOLOGY
PRINCIPAL, COLLEGE OF PURE AND APPLIED SCIENCES
_______________________________________________________________________
STUDENT APPLICATION/REGISTRATION FORM (CERTIFICATE COURSES)
Surname:___________________________________
Gender:M/F)__________________
Other
Names_____________________________________________________________
Address:_________________POSTAL
CODE____________TOWN:_______________
Telephone:_______________________________________________________________
Email:__________________________________________________________________
Date of Birth:__________________________ ID/Passport
No._____________________
Indicate the course applied for:
Certificate in Mathematics
Certificate in Physics
Certificate in Chemistry
Certificate in Biology
Intake Date:
_____________________________________________________________
Centre of
Study___________________________________________________________
Education:
Schools Attended Date
From (year) to (Year)
Qualification
Attach copies of the following documents:
Relevant certificates KCSE Result Slip/Certificate,
School Leaving Certificate
National ID Card/ID. Application Waiting Card/Birth
Certificate
One Coloured Passport Size Photograph, and
A copy of Application form receipt Noted: The application form
will not be accepted unless all the stated documents above are
attached.
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Sponsorship
Self
Others (Parent, Organization)
_______________________________________________
Name
Address.:___________________________Telephone No.
_________________________
Name and Address of nearest relative/person or agency to be
contacted in case of
emergency
Name;__________________________________
Relationship___________________
Address:_________________________________
Telephone:_____________________
TERMS AND CONDITIONS
Fees must be paid in advance or on the opening date:
1. A 20% will be charged on any booking cancelled before
commencement of class 2. JKUAT does not accept any liability on
loss or damage to any property brought or left on
the premises by students.
3. JKUAT does not accept any liability whatsoever for any
injuries incurred during the training.
4. Students will be charged for any damage caused to
equipment.
DECLARATION:
I _______________________________________________________
declare that the
information given in this application form is correct. I further
certify that I have read,
understood and agreed to comply with the terms stipulated
herein:
Signature_____________________________ Date:
___________________
FOR OFFICIAL USE ONLY
SNo Receipt
No.
Sponsor Date
Received
Qualified Documents
verified
Selected
Signature_____________________________ Date:
___________________
DEAN, SMS / SPS / SBS
