Mukuba College of Education

Course of Choice

First Choice

Second Choice

Third Choice

Personal Information

First name:

Please provide your first name.

Last name:

Please provide your last name.

Other names:

Address:

Please provide your address.

Email:

Please provide a valid email address.

Phone:

Please provide a valid phone number.

Dob:

Please provide your date of birth.

Age:

Please provide your age.

Sex:

Please select your gender.

Birth place:

Marital status:

Please select your marital status.

Financial Information

Financial support:

Please describe your financial support.

Family support:

Please describe your family support.

Dependents Information

Name	Age	Sex	Relationship	Action

Next of Kin

Primary Next of Kin

Kin1 name:

Please provide primary kin's name.

Kin1 relationship:

Please specify relationship.

Kin1 phone:

Please provide valid phone number.

Kin1 known duration:

Kin1 address:

Please provide address.

Secondary Next of Kin

Kin2 name:

Kin2 relationship:

Kin2 phone:

Kin2 known duration:

Kin2 address:

Medical Information

Health description:

Please describe your health condition.

Do you have any disability?

Yes

No

Have you had any mental or psychological problems?

Yes

No

Do you smoke?

Yes

No

Do you drink alcohol?

Yes

No

Have you ever been in trouble with the law or convicted of a crime?

Yes

No

Education Background

Institution Type	Institution Name	Year Attended	Certification Obtained
Primary School
Secondary School
Senior Secondary School
College/University

Personal Statement

Program reason:

Please explain why you want to join this program.

Training use:

Please explain how you'll use this training.

Referees

Referee 1

Referee1 name:

Please provide referee's name.

Referee1 phone:

Please provide valid phone number.

Referee1 known duration:

Referee1 address:

Please provide address.

Referee1 relationship:

Please specify relationship.

Referee 2

Referee2 name:

Referee2 phone:

Referee2 known duration:

Referee2 address:

Referee2 relationship:

Acknowledgement

I hereby certify that the information in this application is true to the best of my knowledge and belief. I further acknowledge my substantial agreement with the college statement of education and agree to obey the rules and regulations if accepted as a student.

You must agree to this statement.

I understand that I will be contacted for personal interviews and the referees I have listed will be contacted.

You must agree to this statement.

If accepted for the course, I understand that I will be dismissed as a student at the discretion of the college officials at any time if there are reasons that I am no longer fit to continue as a student.

You must agree to this statement.

Application fee is K200 non-refundable (kindly use applicant reference code shown above).

Required Uploads

Grade12 cert: Accepted formats: PDF, JPG, JPEG, PNG (Max 5MB)

Passport photo: Accepted formats: JPG, JPEG, PNG (Max 2MB)

Nrc copy: Accepted formats: PDF, JPG, JPEG, PNG (Max 5MB)

Deposit slip: Accepted formats: PDF, JPG, JPEG, PNG (Max 5MB)

Deposit money to account 0082040000488 INDO ZAMBIA BANK, Kitwe branch. Kindly send copy of deposit slip to the following WhatsApp numbers to receive your receipt: +260 97 1234567, +260 95 7654321

School Application Form