Application Fee (Non-Refundable): K150

Application Form for Skills / Short Programs

Luanshya Institute of Agriculture and Engineering Innovations | Plot No. 1425/1 - Section One, Mortuary Road, Luanshya

NOTE: All practical courses are not offered online.

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Course Applied For *

Part A: Personal Details

Title

Surname *

Other Names *

Gender *

Male Female

Date of Birth *

NRC / Passport No. *

Nationality

Residential Address

Postal Address

Age (Years) *

Email Address

Mobile Number *

Next of Kin *

Relationship

Next of Kin Address

Next of Kin Phone

Commencement Date

Mode of Study *

Full Time Online

Professional Qualifications Relevant to Course

Any Other Qualifications

How did you hear about LIAEI? (Click one)

Name of Agent (if applicable)

Agent NRC

Agent Cell

Part B: Declaration by Applicant

I declare that the information provided, to the best of my knowledge is true and I promise to abide by institution rules if offered a place.

I agree to the above declaration and confirm all information is accurate.

Electronic Signature *

Luanshya Institute of Agriculture and Engineering Innovations

Plot No. 1425/1 - Section One, Mortuary Road, Luanshya

APPLICATION FORM FOR SKILLS / SHORT PROGRAMS

COURSE APPLIED FOR:

PART A: PERSONAL DETAILS

Surname:	Other Names:
Gender:	Date of Birth:
NRC/Passport No:	Nationality:
Residential Address:
Postal Address:	Age: Years
Email:	Mobile No:

Next of Kin: | Relationship:

Kin Address: | Kin Phone:

Commencement Date: | Mode of Study:

Professional Qualifications:

How did you hear about LIAEI?

PART B: DECLARATION BY APPLICANT

I declare that the information provided, to the best of my knowledge is true and I promise to abide by institution rules if offered a place.

Signature:

Date:

PART C: FOR OFFICIAL USE ONLY

Student Suitable / Not Suitable: ........................................................................

Name of Approving Officer: ........................................... Signature: .......................... Date: .....................