OLUSEGUN AGAGU UNIVERSITY OF SCIENCE AND TECHNOLOGY
(OAUSTECH), OKITIPUPA
For Society and Development
Affix Passport
photograph
2022/2023 ACADEMIC SESSION
NEW STUDENT SCREENING FORM
1. Full Names:……………………………………………………………………………………………………………………………………..
Surname First Name Other Names
2. School: ……………………………………. Department:………………………………… Programme…………………….........
3. Mode of Entry:…………………………………………………………………………………………………………………………………..
4. UTME/DE Registration No:…………………………………………………………………………………………………………………
5. UTME SCORE/DE GRADES:………………………………………………………………………………………………………………...
6. State your JAMB Examination Centre and Town:………………………………………………………………………………..
7. Home Town:……………………………………………. Local Govt. Area:…………………………………………………………….
8. State of Origin:…………………………………,,,,,,,Nationality:……………………….Gender…………………………………..
9. Phone Number:…………………………………….E-mail Address…………………………………………………………………….
10. Date of Birth:…………………………..Marital Status……………………………………Religion:………………………………..
11. Permanent Home Address:…………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………
12. Contact Address:…………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………..
13. Name of Next of kin
(Parent/Sponsor):………………………………………………………………………………………………………………………
14. Phone No of Parents/Sponsor:……………………………………………………………………………………………………………..
15. E-mail Address of Next of Kin:………………………………………………………………………………………………………………
16. Address of Parents/Sponsor:…………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………..
17. Health Status
State ailment (if any) ……………………………………………………………………………………………………………………………
Medication Required ……………………………………………………………………………………………………………………………
State specific disability (if any)………………………………………………………………………………………………………………
18. Attestation by students:
I affirm that all information given by me herein is true, that all documents submitted by me are
authentic:
I further aver that I have never been a member of any secret cult and that if any of the statements is
found otherwise my admission stands nullified.
…………………………………………………………………………………………………. ……………………………………………………..
Full Names of Student Signature & Date
FOR OFFICAL USE ONLY
OFFICE OF THE DEAN AND HOD
S/N DOCUMENTS SUBMITTED FOR SCREENING REMARKS
1. Original SSCE/GCE/NECO/NABTEB Statement of
result
2 Original result of A’ Level, National Diploma and
other certificates for Direct Entry candidates
3 Original JAMB result for UTME candidates
Items Checked by _________________________________________ _____________________
Full Name of HOD Signature and Date
Items Confirmed by __________________________________ ________________________
Full Name of DEAN Signature and Date
ACADEMIC AFFAIRS OFFICE
S/N DOCUMENTS SUBMITTED FOR SCREENING REMARKS
1 Letter of Admission issued by JAMB
2 Letter of Reference from a reputable
Clergyman/Lawyer/Senior Civil Servant
3 Birth Certificate
4 Local Government/State of Origin
5 Medical Record of Fitness (To be collected at
the University Health Centre)
6 Screening form completed by the student
7 Student self-declaration against cultism form
completed by the student
8 Bio Data form
Items Checked by:…………………………………………………………………………. …………………………………
Full Name of ACADEMIC AFFAIRS OFFICER Signature & Date
