- Cape Coast Polytechnic

CAPE COAST POLYTECHNIC
APPLICATION FOR ADMISSION
INTO NON-TERTIARY PROGRAMMES OF STUDY
Affix
Passport
Picture
Applicants are requested to send two (2) completed forms to the Office of the Registrar to reach him not later
than……………………………………………………….. with:
a)
b)
c)
d)
Four (4) recent passport-size photographs.
Endorse on the reverse side of (1) copy.
Write at the back of the remaining 3 copies your name and programme applied for:
Affix one copy to each Application Form.
Any applicant who provides false information on the Form will be refused admission, or if he/she has already been
admitted will be withdrawn from the Polytechnic.
(PLEASE COMPLETE IN BLOCK LETTERS)
1. Programme Applied for:
1st Choice………………………………………………………………………………………...
2nd Choice…………………………………………………………………………………………
2. Personal Details of Applicants:
(i)
Surname:
Mr./Mrs./Ms…………………………………………………………………………………….
(ii)
Other name(s)…………………………………………………………………………………..
(In full, not abbreviated and in the same order as on your certificates)
(iii)
Permanent Postal Address:……………………………………………………………………
………………………………………Email Address (if any)……………………………................
(iv)
Date of Birth:…………………………………………………………………………………....
(v)
Nationality:………………………………………………………………………………………
(vi)
Place of Birth:……………………………………..District:……………………………………
(vii)
Home Town:……………………………...................Region/District:…………………………
(viii) Telephone number:………………………………………………………………………………
3. Particulars of Parent/Guardian:
(i)
Parent’s/Guardian’s Name:………………………………………………………………………
Relationship:……………………………………………………………………………………..
(ii)
Address of parent/Guardian:……………………………………………………………………..
……………………………………………………………………………………………………
(iii)
Parent’s/Guardian’s Occupation:…………………………………………………………………
4. Educational Background
Name(s) of Institution(s) attended
DATE
(i)
…………………………………………………………………From………………To…………
(ii)
…………………………………………………………………………………………………….
(iii)
……………………………………………………………………………………………………..
(iv)
……………………………………………………………………………………………………
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5. Examination passed or taken
(a) WASSCE/SSCE/GCE “O” Level/Craft Intermediate/Ghana Commercial Examination II/City &
Guilds/Technician I/NACVET/NVTI
(i)
Month:…………………………………………… Year:……………………………………….
(ii)
Exam. Index No.:………………………………………………………………………………..
(iii)
Exam. Center:……………………………………………………………………………………
(iv)
Examination Results
Subject
Grade
Subject
Grade
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
6. Endorsements
(a) Declaration and Signature of Applicant:
I declare that that the information provided is correct. I understand that any offer of admission may be withdrawn if
the information provided is fraudulent or if I cannot provide documentary evidence.
…………………………………….
Signature of Applicant
…………………………………….
Date
(b) Endorsement by Referee
This form must be endorsed by someone of high repute who must read and sign the following declaration.
I certify that the applicant is personally known to me and that I have vetted both the photograph and the claims
contained in this application and that to the best of my knowledge, the information can be said to be true.
Name:……………………………………………………………………………………………………………..
Signature:………………………………………….............Date:………………………………………………..
Address:………………………………………………………………………………………………………………
……………………………………………………………………………………………………………..
7. Official use Only
Selected
Not Selected
Finance Office Use Only
Receipt Number
Date
Application Fee
Completed Application Forms should be returned to
The Registrar
Cape Coast Polytechnic
P. O. Box AD 50
Cape Coast.
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