FCT SCHOOL OF NURSING AND MIDWIFERY
TEACHING HOSPITAL ABUJA, NIGERIA. APPLICATION FORM
APPLICATION FORM FOR 2025/2026 ACADEMIC SESSION
FORM NO: 00778
COURSE OF DISCIPLINE:
Name of Candidate:
Contact address:
SECTION A: PERSONAL DETAILS
Telephone No: Email:
Date of Birth (dd/mm/yyyy
Nationality: L.G.A: State Of Origin:
Religion: Denomination:
Marital status: Maiden name:
PARENT/GUARDIAN DETAILS
Occupation:…………………………………………………………………………………………………………………
FOR OFFICIAL USE ONLY
Date Application Form was Issued:_____________
Receipt No.:____________ Date:______________
Application Fee Paid:__________ Date:________
Officer Signature/Date:_____________________
Date:______________
APPLICATION REQUIREMENT
Passport Photographs (2) Photocopies of Results
Birth Certificate/Age Declaration Local Government of Origin
DIRECT ENTRY:
FIRST CHOICE OF
SECOND CHOICE OF STUDY:
SECTION C: ACADEMICS RECORDS
EXAMINATION TAKEN WITH RESULT
WAEC/SSCE NECO A LEVEL/OTHERS GCE O’ LEVEL
SUBJECT GRADE SUBJECT GRADE SUBJECT GRADE SUBJECT GRADE
SECTION D: DECLARATION
I solemnly declare that all the information provided by me above is correct and true. I, therefore, accept responsibility for any inaccuracies and/or falsification which Fct School of Nursing and Midwifery management may discover and consider grave enough to lead to the termination of my studentship at any time during my stay in the Fct School of Nursing and Midwifery or even to the withdrawal of any certificate awarded based on the information. I also promise to abide by all rules and regulations.
Full Name Signature Date
COUNTER-SIGNED BY PARENTS/GUARDIANS
I,…………………………………………………………………………………… certify that I am the ……………………… (State relationship) to …………………………………………………………………. (Candidate full name) .I confirm that the information given in SECTION A AND B above by the candidate and also endorse the declaration by him/her in SECTION C.
NAME OF COORDINATOR: _
COMMENT:
DATE OF REGISTRATION:
SIGNATURE: