Application Form

2019 YOUTH EMPOWERMENT PROGRAMS

August 12 – 23, 2019

Delivery Partners: Bennie Agro Nig. Ltd, Univelcity, Yadaversity & Ripples Event Management

PLEASE USE CAPITAL LETTERS TO FILL THIS FORM

Application Requirements
Students Program: Must have graduated with good grades from High School or University (Ages 17 to 26)

1. PERSONAL INFORMATION

* Indicates required field

SURNAME *

MIDDLENAME *

FIRSTNAME *

DATE OF BIRTH *

MALE/FEMALE *

MALE FEMALE

COUNTRY OF CITIZENSHIP *

Phone Number *

SCHOOL NAME *

GRADUATION YEAR *

HAVE YOU GRADUATED FROM ACCREDITED UNIVERSITY WITH AT LEAST A SECOND CLASS LOWER?

SCHOOL NAME *

GRADUATION YEAR *

CITY & STATE OF ORIGIN

CITY *

STATE/REGION *

COUNTRY *

CHOICE OF PROGRAM: Kindly tick two program from choices listed below: (Mark ‘X’ on desired option) *

TECHNOLOGY & WEB DESIGN AGRO EQUIPMENT DESIGN VIDEO PRODUCTION EVENT PLANNING & CATERING

2. SCHOOL CONTACT (E.g. Principal/Lecturer)

Title (Mr/Mrs/Dr) *

Surname *

Given Name(s) *

POSITION: *

EMAIL ADDRESS: *

PHONE NUMBER(S): *

3. FAMILY/GUARDIAN INFORMATION

Please provide the following information on your parent(s) or guardian(s).

NAME: *

RECENT PASSPORT *

Max file size: 20MB

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