PENTECOST UNIVERSITY
P.O.Box N739, Kaneshie, Accra-Ghanaa
Passport
Tel: 302417057/8, Website:www.pentvars.edu.gh
Photograph
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SCHOOL OF THEOLOGY, MISSION AND LEADERSHIP
CERTIFICATE IN CHRISTIAN MINISTRY (CICM)
STUDENT INFORMATION Form No._______
NAME (In Capitals) SURNAME TITLE
FIRST NAME OTHER NAMES
*Names must correspond exactly with those used for all examinations taken. Provide Legal proof of any change in name
DATE OF BIRTH PLACE OF BIRTH GENDER M F
D D M M Y Y Y Y
NATIONALITY HOME TOWN
LANGUAGES
SPOKEN
WRITTEN
MARITAL STATUS SINGLE MARRIED DIVORCED
NAME OF AREA
NAME OF DISTRICT
AREA EMAIL ADDRESS
APPLICANT’S EMAIL ADDRESS
APPLICANT’S CONTACT NUMBERS
ARE YOU PHYSICALLY CHALLENGED? YES NO
IF YES, PLEASE SPECIFY
EDUCATIONAL BACKGROUND
1.
2.
3.
4.
EMPLOYMENT DETAILS
DO YOU HAVE INTERNET ACCESS FOR ONLINE STUDIES YES NO
REFERENCES (TWO REFEREES, PREFERABLY YOUR AREA HEAD AND YOUR DISTRICT PASTOR)
1. NAME POSITION SIGNATURE
2. NAME POSITION SIGNATURE
DECLARATION
DATE_________________________
I ____________________________________________________ DECLARE THAT ALL THE PARTICULARS
FURNISHED BY ME ON THE APPLICATION FORM ARE GENUINE AND REFLECT MY TRUE RECORDS
DATE__________________________ SIGNATURE___________________
FOR OFFICE USE ONLY
NAME SIGNATURE
AMOUNT C DATE
COMPLETED APPLICATIONS SHOULD BE SENT TO
fassrpong@pentvars.edu.gh and ctsekpoe@pentvars.edu.gh
FOR FURTHER INFORMATION CONTACT
0244072950/0242635815
