Modal College Express Admissions

Express Admission: Student Information

Items marked * are required
Student's Full Name*

PrefixFirst NameLast Name
Student's Mobile Number*
Number with your Country Code
E-mail*
Programme*

BSc NursingDiploma in NursingHAC/NACHND Medical LaboratoryHND Information and Communication TechnologyHND Electrical and Electronic EngineeringHND Automotive EngineeringHND Business AdministrationHND Banking and FinanceDBS Business AdministrationDBS Banking Technology and Accounting
AFFIX A PASSPORT SIZE PHOTOGRAPH WITH A WHITE BACKGROUND

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MODAL COLLEGE

The Admission Office, P.O. Box SK 172 Sogakope, Volta Region, Ghana
Mob. +233 552482220, +233 207686304
Website: www.mocalcollege.com

GENERAL INFORMATION

Please read all information on this form carefully before completing the form. Apply as early as possible to avoid disappointment as competition is keen.
Please complete this form in BLOCK letters.
PERSONAL INFORMATION
TITLE*

MrMissMrsOther
SURNAME*
MAIDEN SURNAME*
if applicable
FIRST NAME(S)*
DATE OF BIRTH(Note the format MM, DD, YYYY)*

MonthDayYear
Date
GENDER*

MaleFemale
NATIONALITY*
MARITAL STATUS*

MarriedSingle
RELIGION*
PHONE NUMBER*

Area CodePhone Number
EMAIL*
example@example.com
PERMANENT HOME ADDRESS (This address will be used forCorrespondence unless you give anAlternative address )*

Street Address

Post Office Box

CityRegion

Command GPS
CORRESPONDENCE ADDRESS (Please leave section if the address is the same as the address provided above )

Street Address

Post Office Box

CityRegion

Command GPS
EMERGENCY CONTACT
Name*

First NameLast Name
Relationship *
Phone Number*

Area CodePhone Number
Address*

Street Address

Post Office Box Address

CityRegion

Command GPS

RECENT EMPLOYMENT Indicate any employment record. Start with present employment*

	Employer	Position in Employment	Date From	Date To

ACADEMIC INFORMATION
PROGRAMME INFORMATION

Please state the full title of the programme(s) to which you are academically qualified for each choice
Title of Programme (As indicated in the Entry Requirements)
First choice*
Second choice
Third choice
Fourth choice
ENTRY LEVEL Please tick the qualification with which you are applying*

WASSCENOV/DECSSCEO'LEVELA'LEVELABCEOther

EDUCATIONAL BACKGROUND Please list in chronological order all academic institutions attended. Also state the dates during which you attended these institutions*

	NAME OF INSTITUTION (Indicate the region in which the school is located)	DATES ATTENDED (Example 2003-2007)

ENTRY QUALIFICATIONS Please list the qualification with which you are applying, including grade obtained in every examination you took. Attach photocopies of transcript and certificates of all the examination you list below. INDICATE IF YOU ARE AWAITING EXAMINATION RESULTS.*

	EXAMINATION TITLE (Example SSCE)	MONTH AND YEAR ATTEMPTED (Example June 2006)	INDEX NUMBER (Example 00103620202)

Attach photocopies of transcript and certificates of all the examination you list above and of your birth certificate.*

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Examination Taken

WASSCE GRADESSSCE GRADESOther

Grade*

	Subjects Taken Please specify 1st, 2nd or 3rd attempts	GRADE

NON-WAEC EXAMINATION and FOREIGN APPLICANTS ONLY (Post Diploma – Diploma in Education – International Baccalaureate). Attach photocopies of transcript and certificates

	Name of the Institution	Date	Grade/GPA	Class/Honour

DECLARATION(Must be filled and signed by the applicant) Declaration and signature of the applicant. I (FULL NAME)*
declare that the statements on this form are correct. I understand that any offer of admission may be withdrawn if the information provided is fraudulent or if I cannot provide documentary evidence.
Signature
Date*

MonthDayYear
Date
ENDORESEMENT. (This form and the three (3) passport size photographs must be endorsed by a Senior Public Officer not below the rank of Assistant
Director, Lawyer or a Medical Doctor.)

I certify that the applicant is personally known to me, that I have vetted the photographs attached and the information
contained in this application and that to the best of my knowledge, the information can be said to be true.
Signature
Full Name*

First NameLast Name
Address*
Date*

MonthDayYear
Date

Finance Office Only


Receipt Number:
Received By:

Official Use ONLY


Selected:
Date:
Incoming Level:
Signature

Submission Date

DayMonthYearHourMinutesAM/PM Option
Admission Fees
Should be Empty:

Express Admission: Student Information

PERSONAL INFORMATION

EMERGENCY CONTACT

ACADEMIC INFORMATION

PROGRAMME INFORMATION