Official Use Only THE COPPERBELT UNIVERSITY

Receipt No……………............
Affix one (1)
Date of Receipt of Completed Passport Size
Form……….............................
Picture Here
Received by: ………………….

Application No.........................
SCHOOL OF GRADUATE STUDIES
P. O. Box 21692
Data Entry By:.........................
Kitwe - Zambia
Batch No:........................... Tel: 002600-212-22543
Fax: 260-212-225434
ACCEPTED REJECTED E-mail: acaofice@cbu.ac.zm

INSTRUCTIONS
1. Please read through the form carefully before filling.
2. Provide information where appropriate.
3. Use Black ink (Ballpoint pen) to fill in.
4. ` Please print in Block Letters.
5. Submit the completed form to:

Applications and Admissions Officer

Academic Office
Copperbelt University
Post Office Box 21692
KITWE

6. Make sure you attach all supporting documents for your application.(NRC, Grade 12 cert. First
degree certificate and transcript of results. etc.)
7. Attach three (3) passport size photographs (One must be affixed on the Form as indicated above
8. An application that fails to comply with the instructions would not be processed
9. Enclose the Two (2) References from your Referees

Degree Programme Applied For: PhD MPhil MSc MA MBA

Name of Programme: …………………………………………………………………………………………......
Mode of Study: Full Time Evening Distance Research
School / Institute of Programme…………………………………………………………………………………
Date of Commencement of Programme: ……………………………………………………………………....

SECTION A
PERSONAL INFORMATION
1.1 Surname /Family Name (Mr/Mrs/Ms/Miss/Dr)...............................................................................
1.2 First Name:.......................................................Middle Name.......................................................
1.3 Sex: Female Male Date of Birth....................................................
1.4 Nationality: Zambian Non- Zambian

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1.5 Mobile Phone Number: ....................................... Email Address ...............................................

SECTION B
ADDITIONAL PERSONAL INFORMATION
1.6 Home Address:..............................................................................................................................
.......................................................................................................................................................
1.7 Postal Address:..............................................................................................................................
1.8 Work Address:..................................................................................................................
1.9 Telephone Number @Work Place:.................................... Fax No: .......................... ......
1.10 If Non- Zambian, what is your nationality? .....................................................................
1.11 If you are not a Zambian Indicate which is applicable
SADC Other National
1.13 Indicate Proficiency in English Language
... Excellent Very Good Good Poor
1.14 Have you previously been enrolled at this institiution? YES NO
1.15 If Yes provide your CBU Student Number
SECTION C
2.0 QUALIFICATIONS OBTAINED
2.1 Please attach certified copies of your degree certificate(s) or transcripts with this
appllication.

University or Dates of Qualification Date of Degree

College Attended Attendance Obtained Award Clarrification

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 2.2 Give details of your career postions to date (you may use additional sheet of paper if
necessary)

Dates Establishment Position Held Nature of Responsibility

SECTION D
3.0 PERSONAL BRIEF
3.1 Provide reasons why you want to pursue graduate studies (You may use additional
sheet of paper if necessary)

.......................................................................................................................................
.......................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
3.2 How will the graduate programme of study affect your personal development
.........................................................................................................................................
.........................................................................................................................................
3.2 How will the graduateprogamme of study affect your career plans.................................
.........................................................................................................................................
.........................................................................................................................................
..........................................................................................................................................
........................................................................................................................................

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SECTION E
4.0 FUNDING OF YOUR STUDIES
4.1 Provide evidence of financial support for your study (If self sponsorship you have to
attach Bank Statements to show that you are capable to pay the fees).
4.2 If institutional sponsorship please attach the committment letter from your institution.

5.0 REFEREES IN SUPPORT OF YOUR APPLICATION

5.1 Give names and addresses of two (2) referees

1. Name of Referee: ..............................................................................................

Address:..............................................................................................................
Telephone No. ................................ Email Address...........................................

2. Name of Referee: ..............................................................................................

Address: ............................................................................................................
............................................................................................................................
Telephone No. ................................Email Address...........................................

5.2 Please request the referees to provide you with References. The references must be
sealed and signed on.

6.0 CLOSING DATE FOR SUBMISSION OF APPLICATIONS

Completed application forms must be submitted to the Deputy Registrar (Academic) by
Wednesday 31st October 2012.

7.0 DECLARATION
I declare that the information provided by me in this application is correct and complete. I
authorise the Copperbelt University to reserve the right to vary or reverse any offer of
Admission made on the basis of incorrect or incomplete information.

SIGNATURE:...............................................DATE OF APPLICATION:.......................................

4
REFERENCE FORM I ( ACADEMIC )

The Copperbelt University

School of Graduate Studies
Kitwe, Zambia
FOR APPLICANT’S USE

Name of Applicant: .........................................................................................................................

Degree Programme Applied For: PhD MPhil MSc MA MBA

Name of Programme: ……………………………………………………………………………………
Mode of Programme: Full Time Evening Distance
School of Programme: …………………………………………… Code
Department of Programme: …………………………………………………………………………….
Date of Commencement of Programme: ……………………………………………………………...

FOR REFEREE’S USE

The above candidate is applying to the Copperbelt University for admission to postgraduate study.
It would be of significant assistance to the University in considering his or her application if you
would kindly complete this form or attach a reference addressing the questions below.

1. For how long and in what capacity have you known the applicant? ......................................
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
2. What is your assessment of the intellectual ability of the applicant? ………………………….
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
What is your assessment of the applicant’s academic potential and ability to handle a
graduate study programme and advanced research work………………………………………
 …………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
3. What are the applicant’s main strengths and weaknesses in a
professional/scientific/academic context?
Strengths: …………………………………………………………………………………………….
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Weaknesses: ………………………………………………………………………………………..
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
4. Please rate the applicant in comparison to his/her peers

Average Below
Top 5% Top 10%
Criteria for Assessment 50% Average 50%

Intrinsic intellectual ability

Creativity and originality
Breadth of general knowledge
Emotional Maturity
Seriousness of purpose
Quality of oral expression
Ability to work with others
Academic performance
Analytical ability
Ability to conduct individual research
5. What is your overall recommendation of the applicant’s ability to pursue postgraduate
study?
 I highly recommend the applicant
I recommend the applicant
I do not recommend the applicant
I recommend with reservation

6. If you wish to provide additional information you perceive may be relevant please you are
free to do so in the slot given below or a separate sheet of paper:
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………

Referee’s Signature: ………………………………………… Date: ……………………………...

Name: ……………………………………………………........ Position: ………………………….
Name of Institution: ………………………………………………………………………………….
Address: ………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Telephone No. at Work: ……………………………… Cell Phone No: …………………………

Official Stamp here

To guarantee confidentiality, it would be appreciated if you would issue this reference under sealed envelope
addressed to Academic Office at CBU. The Sealed envelope must be posted together with the completed form.
REFERENCE FORM II ( PROFESSIONAL )

The Copperbelt University

School of Graduate Studies
Kitwe, Zambia
FOR APPLICANT’S USE

Name of Applicant: .........................................................................................................................

Degree Programme Applied For: PhD MPhil MSc MA MBA

Name of Programme: ……………………………………………………………………………………
Mode of Study: Full Time Evening Distance Research
School / Institute of Programme: ………………………………… ……
Date of Commencement of Programme: ……………………………………………………………...

FOR REFEREE’S USE

The above candidate is applying to the Copperbelt University for admission to postgraduate study.
It would be of significant assistance to the University in considering his or her application if you
would kindly complete this form or attach a reference addressing the questions below.

1. For how long and in what capacity have you known the applicant? ......................................
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
2. What is your assessment of the intellectual ability of the applicant? ………………………….
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
 What is your assessment of the applicant’s academic potential and ability to handle a
graduate study programme and advanced research work………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
3. What are the applicant’s main strengths and weaknesses in a
professional/scientific/academic context?
Strengths: …………………………………………………………………………………………….
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Weaknesses: ………………………………………………………………………………………..
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
4. Please rate the applicant in comparison to his/her peers

Average Below
Top 5% Top 10%
Criteria for Assessment 50% Average 50%

Intrinsic intellectual ability

Creativity and originality
Breadth of general knowledge
Emotional Maturity
Seriousness of purpose
Quality of oral expression
Ability to work with others
Academic performance
Analytical ability
Ability to conduct individual research
5. What is your overall recommendation of the applicant’s ability to pursue postgraduate
study?
I highly recommend the applicant
I recommend the applicant
I do not recommend the applicant
I recommend with reservation

6. If you wish to provide additional information you perceive may be relevant please you are
free to do so in the slot given below or a separate sheet of paper:
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………

Referee’s Signature: ………………………………………… Date: ……………………………...

Name: ……………………………………………………........ Position: ………………………….
Name of Institution: ………………………………………………………………………………….
Address: ………………………………………………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Telephone No. at Work: ……………………………… Cell Phone No: …………………………

Official Stamp here

To guarantee confidentiality, it would be appreciated if you would issue this reference under sealed envelope
addressed to Academic Office at CBU. The Sealed envelope must be posted together with the completed form.