New Student Application
General Information

Campus
First name
Middle Name
Last name
Gender Male Female
Home Phone
Cell Phone
Previous School
Other school
State name of other school
Faith/Religion
Birth Date
Address
VILLAGE  (Required)
Mandatory
Country  (Required)
Nationality
Email
State/Province
Zip/Postcode
Address
Village/City
Country
Picture File
Program (Required)


Guardian Contact Information

Guardian Name
Relationship
Phone
Email
Address
Village/City
Zip/Postcode
State/Province
Country


Permanent Contact Information

NEXT OF KIN  (Required)
Relationship (NOK)  (Required)
Address
Village/City
State/Province
Zip/Postcode
Country
Phone


Emergency Contact Information

Contact Name
Relationship
Home Phone
Work Phone
Cell Phone


Disability Information

DisabilityYes NoNot Selected
Disability Description
Learning DifficultiesYes NoNot Selected
Learning Difficulties Description


Correspondence

File2
File1


Tuition & Fees Payment Information

Tuition Rate
Payment Method
Payment Plan Full Payment

All tuition and fees will be billed according to this payment plan.


I certify that the information on this application is complete and accurate. I understand that the submission of false information is grounds for (1) rejection of my application, (2) withdrawal of any offer of acceptance,(3) cancellation of enrolment, or (4) appropriate disciplinary action. If admitted, I agree to comply with the laws and regulations of the Dominica State College.


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