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**ALL TUITION FUNDS ARE NON REFUNDABLE TO THE STUDENT AFTER 2 WEEKS FROM THE DATE OF ENROLLMENT.

Name:*

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Address:*

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Home Phone:*

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Cell Phone:

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Phone Number

Marital Status:*

Birth Date:*

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year

E-mail:*

College/University:*

College/University (2):

Secondary School & Location:*

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Occupation - Current:*

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Personal Reference (1):*

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Credit Reference (1):*

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Student Signature (type):*

Application Date:*

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Word Verification:

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