ACADEMIC INSTITUTION WITH WHICH THE APPLICANT INTENDS TO STUDY
Name of Institution ………………………………………………………………..
Department/Faculty ……………………………..……………………………..…
Address ……………………………..……………………………..………………
……………………………..…………………………….…………………………
….……………………………..……………………………..…………………….
Telephone Number ……………………………..……………………………..……
Fax Number ……………………………..……………………………..……………
E-mail address ……………………………..……………………………..…………
I certify that the above details are correct
Signature of applicant ....................................................................
Date ...................................................................