All correspondence should be addressed to the Principal In reply please quote ZCA/MP/101/3/4 ZAMBIA COLLEGE OF AGRICULTURE – MPIKA P.O. Box 450143 MPIKA Telephone: +260 214 370 342/ 764 Principal Mobile: +260 977 470 267 Vice Principal Mobile: +260 955 533 553 Executive Officer Mobile: +260 968 591 853/976 871 422 Form No: ........................................................ Training Programme: ...................................................... APPLICATION FORM FOR ADMISSION Applicants should complete and send the form direct to the Principal at the above address Please use block letters 1. Surname: ............................................................................................................................................... 2. Other Names in full: ............................................................................................................................. 3. Sex: .......................... Marital Status: ..................................................................................... 4. Date of Birth: ............................................................................................................ 5. Address where you can be contacted: ................................................................................................... ............................................................................................................................................................... ............................................................................................................................................................... Contact Phone Number: ........................................................................................................................ 6. Nationality: .................................................................................................. 7. National Registration Card Number: .................................................................................................. 8. (a) State the subjects passed at Junior Secondary School Examination level. (Please attach Photostat copy of your certificate or statement of results) NB: Do not send originals. Subject Grade Subject Grade ................................................... ..................... ..................................................... ..................... ................................................... ..................... ..................................................... ..................... ................................................... ..................... ..................................................... ..................... ................................................... ...................... ....................................................... ...................... (a) State the subjects which you entered and passed in senior secondary school examinations or indicating the level of performance. (Please attach Photostat copies of your certificates or statement of results and National Registration Card Subject Grade Subject Grade .................................................... . .................... . .................................................... . .................... .................................................... . .................... . .................................................... . ..................... .................................................... . .................... . .................................................... . ..................... .................................................... . .................... . .................................................... . .................... 9 . Secondary School Attended: Name From To ..................................................................................... ............................. . .............................. .. ..................................................................................... ............................. . .............................. . 10. ..................................................................................... ............................. . .............................. .. ..................................................................................... ............................. . .............................. .. Please state if you have any physical disabilities............................................................................... ......................................................................................................................................................... ... ......................................................................................................................................................... .... 11. Give two referees and their occupations and addresses (relatives will not be considered as referees) (a) ............................................................. (b) ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. ............................................................. Date: ................................................................... Signature: ................................................................... ** Photocopies of this form will not be accepted ** The application form is K50.00 if you are applying the certificate and K80.00 if applying for the diploma programme. **Deposit into the following bank accounts: Finance Bank - 0260101163008 if you are applying for admission to the diploma and ZANACO Student - 1498021300156 if applying for admission to the certificate programme. Please attach the deposit slip to the application letter.