GRN N

APPLICATION FORM FOR ADMISSION

SECTION A: PERSONAL DATA (use capital letters only)

GOODS RECEIVED
1. Surname .......................................................................................................................................
Supplier: ……………………………………………. Delivery date: ………………
Other names ...............................................................................................................................
Delivery locaƟon: …………………………………………………………
2. Date of birth: ................................................................................................................................

3. Place of birth: ...............................................................................................................................

Pack Order Delivered
4. Name of Parents: S/N DescripƟon Co
Size QuanƟty QuanƟty
Father:.................................................................................. Alive? Yes ( ) No ( )
1
Mother: ................................................................................ Alive? Yes ( ) No ( )
2
Father’s contact: ................................................................
3
Mother’s contact:..............................................................
4
5. If the parent is not alive, name of the Guardian.....................................................................
5
6. Gender: Male ( ) Female ( )
6
7. Marital Status: Single ( ) Married ( )
7
8. Nationality ....................................................................................................................................
9
District............................... Home town........................................................................................

9. 12 ........... Protestant ( ) Muslim ( ) Other ..............

Religious Affiliation: Catholic ( ) Diocese

13 application should be sent:

10. Address to which communication on this

........................................................................................................................................................
………………………………………………………….
.......................................................................................................................................................
……………………………………………………………
........................................................................................................................................................

.......................................................................................................................................................

1. AdministraƟon and Accounts department copy

2. Supplier copy
11. Your telephone number ............................................................................................................
3. Stores Goods Inwards copy
12. Your e-mail address ....................................................................................................................
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 13. Your Permanent address (if different from 10 above)
da Rd., Luzira
390, Kampala
1000059513
....................................................................................................................................................
____
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

14. Name and address of next of kin ( specify the relationship eg. Spouse)

……. .....................................................................................................................................................

……… .....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
15. Telephone number of the next of kin
....................................................................................................................................................

16. E-mail address of the next of kin.............................................................................................

17. Occupation of the next of kin ................................................................................................

18. Name and address of your sponsor ( if any) .........................................................................

19. Are you currently employed? Yes ( ) No ( )

20. If yes, indicate type and nature of employment ...................................................................

(specify if it is full-time or part-time employment)

21. Name and address of your employer

....................................................................................................................................................
....................................................................................................................................................
.....................................................................................................................................................

…… 22. Telephone number of your employer ....................................................................................

……
23. E-mail address of your employer ............................................................................................

24. Do you suffer from any specific chronic disease? Are you affected by any disability?

Yes ( ) No ( )

25. If yes, please specify .................................................................................................................

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SECTION B: ACADEMIC PROFILE

26. Give your academic qualifications, clearly indicating the levels obtained and when:

Name of school attended From To Qualification (s) e.g. UCE,

(secondary and post- (Month and Year) (Month and Year) UACE, Grade III, GradeV,
secondary) Degree

SECTION C: PROGRAMME YOU ARE APPLYING FOR (tick your choice):

Certificate of Early Childhood care and Education

Diploma in Early Childhood Care and Education

Diploma in Primary Education

Diploma in School Leadership and Management

Bachelor of Primary Education

Bachelor of Science with Education

Bachelor of Arts with Education

Bachelor of Early Childhood care with Education.

Other (Specify)............................................................................................................................................

SECTION D: PERSONAL STATEMENT

Write a brief statement (100-200 words) describing important details of your life, your career goals,
your reason for wishing to obtain a diploma / Certificate you are applying for and the reason why
you particularly wish to study at Luigi Giussani Institute of Higher Education.

...........................................................................................................................................................................

............................................................................................................................................................................

............................................................................................................................................................................

............................................................................................................................................................................

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...............................................................................................................................................................................................................

..................................................................................................................................................................................................................

.................................................................................................................................................................................................................

SECTION E: PERSONAL DECLARATION

I declare that the information provided in this application is correct at the time of completion: that I
have disclosed all information that may be revelant to my application; and that the personal
statement is my own work.

................................. ..............................

Signature of the Applicant Date

SECTION G: CHECKLIST OF REQUIREMENTS

Please include the following with your application form:

i. Two certified photocopies of all your relevant pass slips and academic certificates/
transcripts (these will be verified against the originals at the time of registration)
ii. A non-refundable fee of Ug. Shs 30,000/=
iii. Three recent Passport size photographs

SECTION G: APPLICATION DEADLINE

This application form and all the accompanying documents should reach Luigi Giussani Institute of
Higher Education
As advised by the officer in charge (Academic Registrar).

FOR OFFICIAL USE ONLY

Application Form No.................................. Date of Admission:......................................

Name of Applicant.....................................

Date received ............................................

Received by ...............................................

Remarks.....................................................