Application Form

CALLAN INCLUSIVE EDUCATION INSTITUTE

P. O. Box 707, Wewak, East Sepik Province 531, PNG
Phone: 70545836 or 78557297

APPLIED DIPLOMA APPLICATION FORM

(Please use block letters and indicate a tick (√ ) in preferred box)

Surname: _____________________________ Given Name(s): _____________________________

Home Province: _____________________________ Current Province: ___________________________

Date of Birth: ______/______/_______ Gender: M F File No: __________________

Day Month Year

Current School:___________________________________________________________________________

Position No/Level: ___________________________________________

Correspondence Address: (Please advise office (CIEI) immediately if your address changes).

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Telephone: ___________________ _______________ _____________

Office Mobile Fax

Email:_________________________________________________________________________

May we give your name and phone number to other students? Yes: ______ No: ______

Academic Attainment (Most Recent first)

Issuing Authority Academic Qualification Year Graduated

Note: Please attach photocopies of the academic qualifications you listed here, including a current inspection report and YOUR
TEACHER TRAINING PROGRAM TRANSCRIPT.

Indicate your level of competence in Melanesian Sign Language, if you will choose specialization in hearing
impairment.
a) None __________ c) Intermediate __________
b) Level 1 (Basics) __________ d) Advance ____________
National Department of Education (NDoE) - Teacher Training Institute within the Network of Callan Services
 Application Form

Two specialisation units are offered. You will take only one specialisation unit. Indicate your preference.
a) Hearing Impairment (HI) 
b) Learning Difficulty (LD) 
Indicate your preference mode of study. Full-time  or Flexible 
Write a brief statement of 150 – 300 words on why you want to pursue an Applied Diploma in Special
education. Use your own words. Do not get help from anyone. Do not copy words from another text
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I ………………………………………………………………… completed all particulars of this application form according to

my ability without assistance from anyone

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Signature Date

National Department of Education (NDoE) - Teacher Training Institute within the Network of Callan Services