Attach a Passport photo Kitwe College of Education Application for admission to Primary Teachers’ Diploma by Distance This form should be completed and returned along with supporting documentation as required to the Directorate of Open and Distance Education, Kitwe College of Education, P.O. Box 22596, Kitwe, Zambia. Please complete this form in block capitals or type PERSONAL DETAILS 1. Mr./Mrs./Ms ……………………………………………………………………………………………………………………………………… Surname (Last Name) 2. Other Names ……………………………………………………………………………………………………………………………………… First Name/Middle Names 3. Nationality ……………………………………………………… Sex: Male/Female………………………………………………….. 4. National Registration card Number/Passport number ……………………………………………………………………….. 5. Place of birth ……………………………………………………………. Date of Birth …………………………………………………. 6. Marital Status: Married/ Single/Divorced/ Widowed ………………………………………………………………………… 7. Number of children …………………………………………………………………………………………………………………………… 8. Permanent home address: …………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………….. 9. Postal Address …………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………….. 1|Page 10. Email address …………………………………………………………………………………………………………………………………….. 11. Tel/Mobile phone number …………………………………………………………………………………………………………………. SECTION B NEXT OF KIN 12. Name of next of kin …………………………………………………………………………………………………………………………… 13. Address of next of kin ………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………… 14. Tel/Mobile number …………………………………………………………………………………………………………………………… 15. Relationship to the applicant …………………………………………………………………………………………………………….. SECTION C EDUCATION AND QUALIFICATION 16. Further Education (college) Give details of higher education since leaving secondary school. Please provide information on qualification already obtained and examinations still to be taken. Name of institution Dates (month –year of attendance) Qualification (include class or grade a obtained if known) 2|Page N.B Photocopies of all certificates and course transcripts awarded for these qualifications must be attached to this application. International students are requested to provide official copies of their entire course transcript including explanations of the mark scheme used where possible. 17. Secondary school Last school attended ………………………………………………………………………………………………………………………… Name of School Subjects written Corresponding grades obtained Examining body SECTION D EMPLOYMENT 18. Present Employment…………………………………………………………………………………………………………………………. Employer……………………………………………………………………………………………………………………………………………. Date of employment………………………………………………………………………………………………………………………….. Nature of Employment (give details)………………….……………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………… 3|Page 19. Previous employment (List under the following headings): Date(s) Employer From: To: …………………………………………………………. ….. ………………………. Nature of Employment . …………………………………………. …………………………………………………………. ….. ………………………. . ………………………………………… …………………………………… ……………………. ….. ………………………. .. ……………………………………….. SECTION E FINANCIES 20. If you are admitted to the programme, Name of the sponsor ………………………………………………………………………………………………………………………… SECTION E ADMISSION REQUIREMENTS 21. Payment of K100, 000.00 non-refundable application fee and depositing the other fees in the college KTC project Account No. 0450220002827, ZANACO OBOTE BRANCH KITWE. No cash payment. 22. Possessing a Primary Teachers’ Certificate or Pre-school teachers certificate 23. A school certificate with 5 O levels, English, Mathematics and science inclusive. I have read the conditions set above and I totally agreed to them. I further declare that the information supplied in this form is correct and fully understand the implications outlined for my admission. ………………………………………………………………………. …………………………………………………………… Signature of Applicant Date 4|Page FOR OFFICIAL USE ONLY Signature of Officer making entry ………..…………………………………………………………………………………………………… Date of receipt of Application…………………………. ………………………………………………………………………………………. Date receipt Acknowledged…………………………… ………………………………………………………………………………………… Result of Application………………………………….. …………………………………………………………………………………………… Receipt No. of Application Fee……………………….. ………………………………………………………………………………………. ………………………………………………………… …………………………………………………………………………………………………….. 5|Page