| APP NO. |  |
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| ACADEMIC SESSION |
| 1 | NAME | |
| 2 | LOCAL GOVERNMENT/STATE | Offa /Kwara |
| 3 | NATIONALITY | Nigeria |
| 4 | SEX | Female |
| 5 | DATE OF BIRTH | 2007-06-13 |
| 6 | PERMANENT HOME ADDRESS | RESIDENCE GAA OLOMIFUNFUN OFFA, KWARA STATE |
| 7 | APPLICANT NUMBER | |
| 8 | PHONE NUMBER | 08055953659 |
| 9 | EMAIL ADDRESS | kazeemmukailababatunde@gmail.com |
| 10 | SCHOOL OF | Information Technology |
| 11 | DEPARTMENT | Library and Information Science |
| 12 | PROGRAMME APPLIED FOR | ND Library and Information Science |
| 13 | NEXT OF KIN, PHONE NUMBER & ADDRESS | KAZEEM MUKAILA BABATUNDE, 08055953659, RESIDENCE GAA OLOMIFUNFUN OFFA, KWARA STATE |
I affirm that the information given above is correct and that I am not a member of any unregistered organization/club/society, and will not join any in the course of my studentship.
Note that the information will be verified by the Security Unit of the Institution and if in the course of your study you are found to be given false information/found to belong to any secret cult or you have been precisely expelled from this institution or any other institution, you will be summarily expelled.
| _____________________________ Student's Signature and Date |
_____________________________ Guarantor's Signature and Date |
 Student's Thumb Print |
 |
_____________________________ Commissioner of Oath |
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*To be completed by a Public Servant no below level 13, Legal Practitioner or Councillor.