DIRECT ENTRY APPLICATION FORM
PLEASE ENSURE THAT ALL FIELDS ARE COMPLETELY FILLED
1. Deposit slip No:_________________________________________________
2. Bank Name:____________________________________________________
3. Branch:________________________________________________________
4. Name:__________________________________________________________
(Surname) (Other Names)
5. Date of Birth:___________________________________________________
6. Sex:____________________________________________________________
7. Nationality:_____________________________________________________
8. State of Origin:__________________________________________________
9. Local Government Area:_________________________________________
10.A DETAILS OF O’ LEVEL RESULTS 10.B DETAILS OF O’ LEVEL RESULTS
Examination:
Year of Examination: Examination:
Reg. Number: Year of Examination:
Subject(s) Grade Reg. Number:
Subject(s) Grade
11. JAMB DIRECT ENTRY DETAILS
Direct Entry Login e-Facility Email
Direct Entry Login e-Facility Password
Direct Entry Registration Number
Note that the Direct Entry Login e-Facility email and password required are the details
used by Candidates while registering on JAMB e-Facility Portal .
12. Institution Attended with Date:_____________________________________________________
____________________________________________________________________________________
13. Qualification: _____________________________________________________________________
14. Degree Applied For: _______________________________________________________________
15. Email Address: _______________________________ Mobile Number: ____________________
16. Applicant’s Signature/Date: _______________________________________________________
NEXT OF KIN
A. Name:_________________________________________________________________
B. Place of Work:__________________________________________________________
C. Nature of Work:________________________________________________________
D. Relationship:__________________________________________________________
E. Phone Number:________________________________________________________
F. Contact Address:_______________________________________________________
____________________________________________________________
G. Signature/Date:________________________________________________________
NOTE: Attach photocopies of O’Level Results/A’ Level Result/JAMB Direct Entry
Slip/Birth Certificate and Receipt of purchase.
FOR OFFICIAL USE ONLY
HEAD OF DEPARTMENT RECOMMENDATION:
I support ( ) /I do not support ( ) the candidate’s admission.
Comment(s)
Level Rcommended
Name/Signature/Date
PROVOST’ S RECOMMENDATION:
I support ( ) /I do not support ( ) the candidate’s admission.
Comment(s)
Level Rcommended
Name/Signature/Date
REGISTRAR’S COMMENT(S):
--------------------------------------------------------------------------------------------------------------
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Date Registrar’s Signature.
ANY FALSE DECLARATION RENDERS THIS FORM/ADMISSION INVALID.
