| School of Nursing

Personal Information

Surname *

First name *

Othernames

Maiden Name

Is Your Father Alive? *

Is Your Mother Alive? *

Father/Guardian's Name, Address and Occupation *

Additional Information

Nationality *

State of Origin *

Local Government Area (LGA) *

Country (Non-Nigerian Nationals) *

Date Of Birth *

Place Of Birth

Gender *

Religious Denomination *

Marital Status *

Number of Children

Contact Details

Email *

Contact Address *

Permanent Address *

Personal Phone Number *

NAME AND ADDRESS OF PERSON TO BE CONTACTED IN CASE OF EMERGENCY. (state your relationship with this person) *

Phone Number of Emergency Contact *

Next of Kin Details

Name of Next of Kin *

Address of Next of Kin *

Phone Number of Next of Kin *

Relationship with Next of Kin *

Referee Details

Name of First Referee *

Address of First Referee *

Name of Second Referee *

Address of Second Referee *

Name of Third Referee *

Address of Third Referee *

Health Details

List Physical Disabilities if Any

Do You Have Normal Sight? *

Height *

Weight *

Qualification Details

Do You Have up to Five (5) Credits? *

Do You Have Credit in English Language? *

Which Science Subjects did you get credit in? *

Are you currently registered for any course in this institution?

If currently enrolled in any course, specify course and school

Date the offer was made

Highest Qualification *

Prizes and Special Distinctions

Title of Published Works

Other Languages You Can Speak and Your Fluency Level *

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Study Mode

Study Mode - (Category) *

Study Mode - (Full-time or Part-time?) *

If part-time, how can you adjust the demands of your present employment with those of your study?

WHAT DEGREE, DIPLOMA OR CERTIFICATE OF THIS INSTITUTION DO YOU WISH TO BE CONSIDERED FOR? Indicate the details below

SCHOOL *

*

Special topic within the subject

Educational History

Field of Study

Certification

From

To

Institution

Place

CERTIFICATION	FIELD OF STUDY	INSTITUTION	PLACE	FROM	TO

Employment History

Company/Place

Appointment

From (Year)

To (Year)

Termination Reason

COMPANY/PLACE	APPOINTMENT	TERMINATION REASON	FROM	TO

APPLICATION REVIEW

Kindly review your application to ensure details are correctly filled.

Personal Information

First name:

Surname:

Other Names:

Maiden Name:

Is Your Father Alive:

Is Your Mother Alive:

Father/Guardian's Name, Address and Occupation:

Additional Information:

Nationality:

State of Origin:

Local Government Area (LGA):

Country (Non-Nigerian Nationals):

Date Of Birth:

Place Of Birth:

Gender:

Religious Denomination:

Marital Status:

Number of Children:

Contact Details / Next Of Kin Details

Email:

Contact Address:

Permanent Address:

Personal Phone Number:

NAME AND ADDRESS OF PERSON TO BE CONTACTED IN CASE OF EMERGENCY. (state your relationship with this person):

Phone Number of Emergency Contact:

Name of Next of Kin:

Address of Next of Kin:

Phone Number of Next of Kin:

Relationship with Next of Kin:

Referee Details

Name of First Referee:

Address of First Referee:

Name of Second Referee:

Address of Second Referee:

Name of Third Referee:

Address of Third Referee:

Health Details

List Physical Disabilities if Any:

Do You Have Normal Sight?

Height:

Weight:

Qualification Details

Do You Have up to Five (5) Credits?

Do You Have Credit in English Language?

Which Science Subjects did you get credit in?

Are you currently registered for any course in this institution?

If currently enrolled in any course, specify course and school:

Date the offer was made:

Highest Qualification:

Prizes and Special Distinctions:

Title of Published Works:

Other Languages You Can Speak and Your Fluency Level:

Study Mode

Study Mode - (Category):

Study Mode - (Full-time or Part-time?):

If part-time, how can you adjust the demands of your present employment with those of your study?

WHAT DEGREE, DIPLOMA OR CERTIFICATE OF THIS INSTITUTION DO YOU WISH TO BE CONSIDERED FOR? Indicate the details below

SCHOOL:

:

Special topic within the subject:

Educational History

CERTIFICATION	FIELD OF STUDY	INSTITUTION	PLACE	FROM	TO

By checking the box below, I hereby declare that particulars which I have supplied above are true to the best of my knowledge and belief. I am aware that withholding any information or/and giving false information automatically disqualifies me from gaining admission, if admitted to the UNTH SCHOOL OF NURSING, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, I shall regard myself bound by the statutes, Ordinances and Regulations of the Hospital in so far as they affect me.

APPLICATION FORM