ENR NS001
KUSHINGA PHIKELELA POLYTECHNIC APPLICATION FORM
Accounts Use Only
Application Number:…………………..
ZIMBABWE Receipt Number:………………………...
MINISTRY OF HIGHER & TERTIARY EDUCATION, SCIENCE AND TECHNOLOGY DEVELOPMENT
KUSHINGA PHIKELELA POLYTECHNIC
Application Form for NEW Students Applying for Admission into HEXCO Programmes.
Applicant’s Details
Surname First Name
Date of Birth Place of Birth
Gender e-mail address
Permanent Address
Cell phone Number National I.D. No
Details of Applicant’s Next of Kin
Surname First Name
National I.D. Number e-mail Address
Permanent Address
Cell phone Number Home Phone No.
Relationship with Applicant
Details of Qualifications
‘’O’’ LEVELS
Year Examination Board Subject Passed with at least a ‘’C’’ Symbol/Grade
(e.g Zimsec, Cambridge) Obtained
‘’A’’ Levels
Year Examination Board (e.g Zimsec, Subject Passed Symbol/Grade
Cambridge) Obtained
E-mail address: kushingaphikelela@[Link] Telephone Number: +2636523-24484/5/6 1
KUSHINGA PHIKELELA POLYTECHNIC APPLICATION FORM
Details of Course Applied for in Order of Preference (Course preferred)*
1 2 3
*You will be considered for either second or third choice in the event that you fail to enrol in your first choice class
Person(s) or Organisation Responsible for Paying Your Fees
Name (Surname First) Permanent Address
Contact Details Relationship with Applicant
Undertaking
I, …………………………………………………………………….. National Identity Card Number
………………………………………………………………….do hereby undertake to pay my fees on time and
pledge to abide by all Kushinga Phikelela Polytechnic Rules and Regulations as well as those of
the Ministry of Higher and Tertiary Education, Science & Technology Development if l am offered
a place to train at Kushinga Phikelela Polytechnic.
Signed: ……………………………………………………… Date: ……………………………………………….
Witness: …………………………………………………. Date: ………………………………………………..
Recommended/Not Recommended
by the Head of Department ………………………………. Department Stamp
Name, Signature and Date:
Accepted/Not Accepted
by the Head of Division: ……………………………………. Divisional Stamp
Name, Signature and Date
For Official Use Only
Captured by: Signature Date
The Registrar
The Accountant
E-mail address: kushingaphikelela@[Link] Telephone Number: +2636523-24484/5/6 2