TAYA INSTITUTE COLLEGE -CLZ

EDUCATION WITH A DIFFERENCE

.Aka teens and youths ablaze

Creativity and Innovation through Education is a pathway to a progressive sustainable society

We Are Located on Plot NO. 10812 Twatasha Road, Chawama

P.O BOX 52142 Chawama, Lusaka, Zambia

Tel: +260966885291/0978237037
Email: Changingliveszambia.simplesite.com
Visit our facebook page: Changing lives zambia

1. Course of your choice FULL-TIME

1st choice: Marketing & Entrepreneurship. Full time or distance or part-time (E-Learning✅ )
2nd.Full time or distance or part-time (tick)

2. Personal and family information

Name : COLLINS KASHALA
Home Address : 14 GARDENIA ROAD, AVONDALE, LUSAKA.
Telephone : 0977603038
Date of birth : 20 March 1990 Age : 30. Sex : Male
Place of birth : Chingola. Country of Citizenship : ZAMBIAN

3. Marital status (tick)

SINGLE Engaged
✅

Widower Separated
Married Divorced

4. If married please Give

Name ………………………………………………………………………………………………………….
Spouse ………………………………………………………………………………………………………..
Address ……………………………………………………………………………………………………….

5. Financial information
How do intend to financially support your studies (tick)
Self ✅ . Parents …… organization ……

6. MEDICAL INFORMATION
How would you D escribe Your General Healthy?
Good Fair Poor
✅

7. (a) Do You Have any Physical Disability? Yes No

✅
(b) If yes describe …………………………………………………………………………………………………
…….
8. Have you ever had any mental or psychological problem? No Yes No
❌
9. Do you smoke? Yes No
✅
Do you drink? Yes No
.✅

10.(A) have ever been in trouble with law or convicted crime? Yes No
(b) If yes when and what happened ………………………………………………………… ✅ ………
…………………………………………………………………….
11. Education background
Institution year certification
Primary school Chibote private school 1996-2003 School certificate
Junior sec school Chainda primary school 2004-2005 ………………………….
Senior Secondary Chongwe High School 2006-2008 ……………………………
College/ universities Nill…………… …………… ……………………………
Describe why you want to do this course?
Iam very passionate about marketing firstly, am blessed with a creativity and with a natural gift
of good communication skills with people from all works of life.
Fill in the table below

School Year Grade

chongwe secondary 2008 GCE
school

Address ………………………………………………………………………………………………….
Relationship ………………………………………………………………………………………For how long have
known each other ……………………………………………………
2. Name: Kakwezhi Kashala
Address: Waterfalls area, lusaka.
Relationship :Daughter . Phone NO : 0977603038
For how long have you known each other 8yrs…….

Acknowledgement
I . Collins Kashala Here by certify that the information on this application is true and correct
on the best of my knowledge and believe. I further acknowledge my substantial agreement
with TAYA INSTITUTE statement of education and agree to obey all rules and regulations
accepted as a student.
I understand that this application will be contracted for personal information interviews and
the referees I have listed will be contacted.
If accepted for the course I understand that I will be dismissed as a student at any
description of college officials at my time other reasons where it is determined that
participation is not wise as a student. Therefore I also accept the 80% bursary on tuition
fees which has been given to me.
With this application form I have paid k 100.00 as my application fee which I know is non-
refundable
Date 31/06/2020
Signature:
Attachment
1. Grade 12 certificate copy (GCE)
2. Photocopy of your National Registration Card.
3. 1 latest passport size photos
4. Id fee k100 ( DURING EXAMS)
5. Lab coat fee k 150 ( PSYCHOSOCIAL COUNSELORS)
6. Graduation compulsory (k400)
7. Exam fee k200 termly