EduRole Student Information System

Application form for new students

You are requesting admission to the following programme: Advanced Diploma in Registered Nurse Midwifery
Please complete the following form entirely to successfully complete your application. Click on the steps below to continue.

1 - General information

In this section you will provide basic information needed for your enrolment.

Information	Input fields	Description
1.2 - Intake for Application		Select the intake you are applying for.
1.3 - Nationality
1.4 - Passport or NRC Number		Please enter the ID number provided on your national identification card or passport
1.5 - Surname		Your family name
1.6 - First Name		Your given name
1.7 - Middle name		Optional
1.8 - Sex (Gender)
1.9 - Date of Birth		Minimum age for applicants is 16 years
1.10 - Streetname and number		For example: Munkoyo Street 1583
1.11 - P.O Box		For example: 804040
1.12 - City/Town
1.13 - Phone Number		For example: 0978168860
1.14 - Email Address		Optional (Yahoo, Hotmail, Gmail, etc)
1.15 - Country
1.16 - Disability
1.17 - Marital Status
1.18 - NRC file		Attach your National Registration Card
1.19 - Passport Size Photo		Latest passport size photo
1.20 - Scan/Photo of Deposit Slip		Deposit an application fee of ZMW150.00, upload the proof of payment. Note that your application will not be processed unless a proof of payment is attached

2 - School certificate examination results

Grade code	Grade code	Grade code
English Language	English Literature	Geography
Art	Agriculture Science	Commerce
Mathematics	Principles of Accounts	Phys. Science
Physics	Homecraft/Cookery	Gen. Science
Chemistry	French or Zamb.Language	History
Metal work	Religious Education	Music
Biology	Technical drawing	Computer Science
Civic Education	Other	Other 2

3 - Education background

4 - Next of kin information

5 - Sponsors information

6 - Second and third program choices

7 - Supporting Statement

8 - Submit your application

Information	Input fields	REMOVE RECORD
0 3.1 - Type of certificate
1 3.2 - Name of institution		For example: Evelyn Hone
2 3.3 - Name of certification		For example: Grade 12, or Diploma in Business Studies
Scan of document		Upload the certificate, degree or diploma.

Information	Input fields	REMOVE RECORD
4.1 - Full Name
4.2 - Relationship
4.3 - Phone Number
4.4 - Email
4.5 - Address
4.6 - Town

Information	Input fields	REMOVE RECORD
5.1 - Full Name
5.2 - Sponsorship
5.3 - Phone Number
5.4 - Email
5.5 - Address
5.6 - Town

Information	Selection
6.1 - Second Choice:
6.2 - Third Choice:

Information	Selection
Document with statement.		Provide a written motivation.

Confirm
	I fully understand and agree with the above stipulations.

-DECLARATION-