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Surname

First Name

Last Name

Date of Birth

Gender

Marital Status

Nationality

State

Local Government Area

UTME Number

Score Obtained

First School Leaving Certificate: (5 Credits in one sitting or 6 credits in two sittings including the under listed subjects)

Exam Type

Exam Year

Exam Number

English

Mathematics

Chemistry

Biology

Agricultural Science

Phone Number

Email Address

Address

Home Address

Next-Of-Kin Name

Next-Of-Kin Telephone<

Next-Of-Kin Postal Address

Next-Of-Kin Home Address

Are you suffering\ have you suffered from any type of major disease or illness?

If yes, indicate the illness

Are you allergic to any food or drug?

If yes, indicate the specify allegies

Blood group

Genotype