MANICALAND STATE UNIVERSITY
OF
APPLIED SCIENCES
STAIR GUTHRIE ROAD – BAG 7001
FERNHILL, MUTARE.
UNDERGRADUATE ADMISSION APPLICATION FORM 20…...
INTAKE: FEBRUARY/ MARCH AUGUST/ SEPTEMBER: (tick where appropriate)
N.B: First read the NOTES on the next page, then complete all sections of the form. DO NOT write in the boxes which are for official use
only. Print clearly in ink in the blank spaces and on the dotted lines as required. V i s i t i n g / B l o c k R e l e a s e a p p l i c a t i o n s m u s t b e
s u b m i t t e d w i t h confir mation letter of emplo yment.
RETURN THE FORM BY MAIL OR IN PERSON
PROGRAMME: … … … … … … … … ....................................................................... POINTS
CONVENTIONAL PARALLEL VISITING SCHOOL (tick where appropriate)
PERSONAL DETAILS
TITLE: MR/MRS/MS/DR/MISS/REV/SR/FR
SURNAME:
FORENAMES:
MARITAL STATUS: GENDER
_
NATIONAL ID # PA PASSPORT#
NATIONALITY
COUNTRY OF PERMANENT RESIDENCE
DATE OF BIRTH: - - PLACE OF BIRTH
(D-M-Y)
DISABILITY INFORMATION: Please specify if you have any. This information will be
DISABILITY CODE
kept confidential by MSUAS
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CONTACT ADDRESS: ........................................................................................................................................................................
TELEPHONE NUMBERS: HOME ……………………………………………………………….
(Include country & area code)
CONTACT NUMBER………………………………………………………………......
E-MAIL… … … … … … … … … … … … … … N.B: All correspondence will be forwarded to the above address.
PROSPECTIVE SPONSORS
(e.g. self, parent, guardian or name of organization) ..........................................................................................................................
Are you a university staff dependant Yes No Are you a university staff member Yes No
FOR OFFICE USE ONLY
ACCEPTANCE CODE: ........................................................ RECEIPT NO..........................................................
1. PROGRAMMES OF STUDY FOR WHICH YOU ARE APPLYING
PREFERENCES DEGREE PROGRAMME FACULTY
1 ……………………………………………. ..........................................................................................
2 ....................................................................... ..........................................................................................
3 ………………………………………………. ...…………………………………………………………
TYPE OF ENTRY (tick where appropriate)
Normal Special Mature
2. SCHOOL EXAMINATIONS FOR WHICH RESULTS ARE KNOWN
‘O’ LEVEL SUBJECTS INCLUDING MATHEMATICS AND ENGLISH
YEAR EXAMINATION BOARD SUBJECT RESULT/GRADE
‘A’ LEVEL SUBJECTS
YEAR EXAMINATION BOARD SUBJECT RESULT/GRADE
3. UNIVERSITIES/COLLEGES ATTENDED. (Name, Qualifications, Year)
......................................................................................................................................
......................................................................................................................................
4. WORK EXPERIENCE / EMPLOYMENT. (Indicate Period, Occupation and Employer’s address)
.......................................................................................................................................
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5. NAME AND ADDRESS OF REFEREE NAME AND ADDRESS OF NEXT OF KIN
. …………………… . ……….………………………….
……………………… ……………………………………
Phone/E-mail…………… Phone/E-mail ……………………………
N.B* BEFORE YOU SIGN AND DATE THIS FORM, PLEASE CHECK THAT YOU HAVE
COMPLETED EACH SECTION AND THAT THE INFORMATION IS CORRECT.
I declare that the information I have given is correct, and that should it be found to be false my application will be
disqualified and I will face legal action.
APPLICANT’S SIGNATURE: ………………………………….. DATE: ……/..…./……..
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