Application Form

Gideon Robert University
5th Floor, Room 816, NAPSA BUILDING,

P.O Box 770, Mandahill, Lusaka
Tel: 260 211 223737, 260211295082
Fax 260211223737
Email: admin@gideonrobertuniversity.com/registrar@gideonrobertunivers ity.com
APPLICATION FORM
1. Personal Details
Mr. Mrs. Miss. Ms. Dr. Male Female
Given Names______________________________What is your preferred Name ____________________________
Family Name________________________________________________
Do you want your family name to appear first on all official GRU documents e.g. Transcript/ Parchments? Yes No
Date of Birth ____/________________/_______ (day/ month/ year; e.g. 18/ December/ 1985)
Citizenship/ Nationality _____________________________ Country of birth ___________________________
Have you studied GRU before? Yes No if yes, provide student ID_______________
Do you have a disability or long-term illness? Yes No if yes, please provide details____________
Do you require disability support services? Yes No
2. Address Details
Physical Address
Plot No. and Street _____________________________________________________________________________
Area/ City ____________________________________________________________________________________
State/ Country _________________________________ Zip/ Postcode __________ Mobile No.________________

Telephone __________________________________Fax ___________________ Email _____________________
My mailing address is different from my home address
Address______________________________________________________________________________________
Area/ City
_____________________________________________________________________________________________
State/ Country ________________________ Box No. ____________________Mobile No. _____________________
Telephone ____________________________________ Fax ___________________ Email ___________________
Please Advise Gideon Robert University if you change your Address during the year.
3. Program preferences (please list your program preferences in order of priority)
Program Name Program Code Specialization (if applicable)
1.___________________________________________________ ___________ (_____________)

2. ___________________________________________________ ___________ (_____________)
3. ___________________________________________________ ___________ (____________)
*your first preferences will be processed first. Second and third preferences will be processed only if your first choice
is unsuccessful.
Full-time Part-time Distance Learning (DL)
4. Financial Support
Please indicate your source of financial support and for invoice purposes please attach information of person or
organization paying fees.
I am fully sponsored by Government (attach documentation) I am a private student supported by myself/ family
I am fully sponsored by my employer (attach documentation ) I am fully sponsored by Zambian government Scholarship
5. Academic Records
Please provide all appropriate academic documentation in original or certified/ notarized form.
6. Secondary Studies
Name of school _________________________________________________ Name of school certificate _________
Language of Instruction ________________________Years From: Yr________To: Yr ________Completed Yes No
7. Tertiary/ Higher Education Studies
Name of institution ____________________________________________Name of Award/ Qualification __________
Language of Instruction __________________________ Years From: Yr______ To: Yr. _______ Completed Yes No
Name of institution __________________________________________ Name of Award/ Qualification ___________
Language of Instruction _____________________ Years From: Yr_________ To: Yr _______Completed Yes No
Name of institution _______________________________________Name of Award/ Qualification _______________
Language of Instruction ____________________Years From: Yr._________ To: Yr __________ Completed Yes No
8. Professional Employment/ Experience

Present position________________________________________ Employers _______________________________
Date of service; from _________________ to ________________ Full-time Part-time
Previous position (if any)__________________________________ Employers ______________________________
Date of service; from _________________ to ________________ Full-time Part-time
9. Declaration
I declare that to the best of my knowledge, the information provide by me is true and complete
Official stamp
in every particular. I acknowledge that the Gideon Robert University may vary or reverse any
Decision regarding admission or enrolment made on the basis of incorrect or incomplete
Information provided by me. I authorize Gideon Robert University to make enquiries about
the detail associated with this application. I understand the above conditions and am prepared
to accept them in full. in particular, I understand that I, or my sponsor, will be responsible for
the full cost of programs for which I am seeking admission.
Signature _______________________ Date ____/ ____/ ____

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Gideon Robert University

5th Floor, Room 816, NAPSA BUILDING,

Area/ City ____________________________________________________________________________________

State/ Country _______________ Zip/ Postcode Mobile No.

1._____________________________________________ _ (_________)

Language of Instruction ________________Years From: YrTo: Yr Completed Yes No

7. Tertiary/ Higher Education Studies

Name of institution __________________________________Name of Award/ Qualification

Name of institution ________________________________ Name of Award/ Qualification _

Language of Instruction _________________ Years From: Yr_ To: Yr ___Completed Yes No

Name of institution _________________________Name of Award/ Qualification _

Language of Instruction ________________Years From: Yr._ To: Yr ______ Completed Yes No

8. Professional Employment/ Experience

Date of service; from _ to Full-time Part-time

Previous position (if any)____ Employers

Date of service; from _ to Full-time Part-time

Signature ___________________ Date / /

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