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Application Form

APPLICATION FORM FOR ADMISSION

SCHOOL OF POST BASIC CRITICAL CARE NURSING

UNIVERSITY OF ABUJA TEACHING HOSPITAL, GWAGWALADA, ABUJA

1. Surname*
2. Other Names*
3. Date of Birth*
4. Sex*
5. Maritial Status
6. Recent Passport Photograph
7. Upload Remita receipt or Print out from the bank
8. Local Government
9. State Of Origin
10. Nationality
11. Religion
12. Address
13. Telephone*
14. Email*
15. Current Place of Employment
16. Date of Employment
17. Next of KIN*
18. Relationship
19. Address
20. NOK Telephone no.
21. Sponsor(s)
22. Address of Sponsor(s)
23. Sponsor Telephone no.
24. Type of Sponsorship
25. INSTITUTIONS ATTENDED WITH DATES: (Starting with the most recent)
S/N - NAME OF INSTITUTION - FROM - TO
26. QUALIFICATIONS OBTAINED WITH DATES:
S/N - QUALIFICATION - DATE - REMARK
27. NAME AND ADDRESS OF REFEREES
(Original copies of credentials must be presented for screening during the interview)
Declaration*
- I declare that the information given above is correct

NB: For further enquiries contact- 08056206826, 08055274605 and 08036767591 or by email – intensecare@yahoo.com OR kumode.stephen@uath.gov.ng

EXAMINATION DATE: THURSDAY, 20th AND FRIDAY, 21st MAY, 2021

(Original copies of credentials must be presented for screening during the interview)