MAURITIUS INSTITUTE OF EDUCATION For Office Use Only

Réduit, Mauritius Application No.:

Telephone: 401 6555 Q NQ P
Fax: 454 10 37
Web Site: www.mieonline.org

APPLICATION FORM

(PLEASE COMPLETE THIS FORM IN 2 COPIES AND WRITE CLEARLY IN DARK BLUE OR BLACK INK)

1.
Post: ………………………………………………………….

2. National Identity Card No.:

3. Title: Mr Mrs Miss

4. Surname: .......................................................................................................
Block
Other name(s): ........................................................................................................ Letters
Maiden name (if applicable): ..............................................................................

5. Residential Address: ………………………………………………………………

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

E-mail Address:……………………………………………………………………

Telephone No: Home: ......................... Mobile: ......................... Office: ........................

Date of birth: Age: Nationality: ...............................

6. Education
Names of secondary schools attended: .................................................................................
SC/GCE ‘O’ Level 1st attempt 2nd Attempt 3rd Attempt
Results
Date of Attempt (Month/Year)
Subjects Grades (e.g. 1, 2, 3 ... or A, B, C ...)

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 HSC/GCE ‘A’ Level 1st attempt 2nd Attempt 3rd Attempt
Results
Date of Attempt (Month/Year)
Subjects taken at Principal Level Grades (A, B, C ...)

Subjects taken at Subsidiary Level Grades (e.g. 1, 2, 3 ... or A, B, C ...)

7. Post Secondary Qualifications

Courses/Programmes Institutions Grade Awarded Duration From To

(if degree, state class
and whether with
Honours)
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8. Employment History

(a) Present Employer: .....................................................................................................................

Present Position held: ....................................................... From: ……………To:……………….

Institution/Secondary School:…………………………………………………………….…..

Present Salary: ............................ Period of notice required by employer: ....................

(b) Previous Employment

Name of Employer Period Post held

From To

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9. Other courses, seminars, etc (if any) attended. (Give details, including dates)

.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
.........................................................................................................................................................
10. Indicate
a. Any important articles, books, etc, which you have published or contributed to:

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

b. Hobbies, sports, interests and any other matters you would wish to bring to the attention of the
Institute

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

11. Referees

Referee 1 Referee 2
Name: ................................................................ Name: ................................................................

Occupation: ......................................................... Occupation: .........................................................

Address: .............................................................. Address: ..............................................................

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

Phone No.: ......................................................... Phone No.: .........................................................

(N.B Please obtain their prior agreement to act as referees)

Declaration

I, ..........................................................................................................................................., the
undersigned applicant declare that the particulars in this application are true and accurate and that I have
not willfully suppressed any material fact.

Date: ............................................ Signature: ................................................

NB: Incomplete and inaccurate filling of the form and not supported by relevant documents may entail
elimination of candidates.
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