Student ID *

First Name *

Last Name *

Other Name

Sex * Select... Male Female

Level * Select... 100 200 300 400 600 Other

Program * Select... College of Health Sciences College of Basic and Applied Sciences College of Humanites College of Education LLB Msc MA Phd Diploma Certificate Other

Institution * Select... UG Regular UG City Campus UG Distance UPS Other

Phone *

UG Email address

Guardian * Select... Parent Uncle/Auntie Sibling Friend Other

Guardian Phone *

I have read and agreed to the residency agreement.