KENULE BEESON SARO-WIWA POLYTECHNIC

P.M.B. 20
BORI

OFFICE OF THE REGISTRAR

(ADMISSIONS & REC. UNIT)

RSPT/REG/ST/2

OFFER OF PROVISIONAL ADMISSION ( 2015/2016 SESSION)

ACCEPTANCE FORM
(To be Completed in Triplicate)

1. Name of Candidate in Full: PAUL, SARAH 6. Date and Place of Birth: 1995-09-10

2. School of: ENGINEERING 7. Nationality: NIGERIA

3. Department: CIVIL ENGINEERING 8. State of Origin: RIVERS

4. Sex: F 9. L.G.A. : ASARI-TORU

29 ESUKU COMPOUND
5. Marital Status: SINGLE 10. Postal Address:
IDO, ,

11. Name and Address of Sponsor: SUNDAY , 29 ESUKU COMPOUND IDO

12. DECLARATION

I PAUL, SARAH accept the offer of provisional admission into the School of ENGINEERING in the Department of CIVIL
ENGINEERING I have paid the sum of N20,000.00 (Twenty Thousand Naira) as Non-refundable deposit. I understand also that I
shall be withdrawn from the Polytechnic any time without further formalities if my qualifications are deficient, and if it is discovered
that I have made false declaration regarding my credentials.

I shall comply with the rules and regulations of the Polytechnic, and especially in respect to discipline, maintenance of law and
order, and if found guilty of involvement in acts of indiscipline I understand and agree that I shall be expelled from the Polytechnic
without formalities.

SIGNATURE OF STUDENT AND DATE:______________________________________________________________

In the presence of:

SIGNATURE OF WITNESS AND DATE:__________________________________________________________________

FULL NAMES OF WITNESS:__________________________________________________________________________

STATUS OF WITNESS:______________________________________________________________________________

ADDRESS OF WITNESS:_____________________________________________________________________________

Note: This declaration must be completed and signed before a witness, who must be one of the following persons:

1. High Court Judge/Magistrate

2. Minister of Religion
3. A Member of the Armed Forces and the Police of the rank not below that of Deputy Superintendent of Police
4. Principal of School
5. Chairman of Local Government Council