APPLICATION FOR RE-

RE-ADMISSION

__________________________________________________________________________________________
______________________________________________________________________________________
Surname First Name Previous surname

Dr Mr Mrs Ms Miss

Address: ___________________________________________
___________________________________________________________________________
_______________________________________

__________________________________________________________________________
__________________________________________________________________________________________

Date of Birth ____/___/____ Student No. _____________

____________________ID or PP# _____________
______________________
DD MM YYYY

Tel: Home:______________Mobile:______
Mobile:____________ Work:____________ Email: _________________________
_______________________

PROGRAMME LEVEL:
LEVEL: Bachelor’s Degree Associate Degree Certificate Diploma Other

PROGRAMME NAME:
NAME ________________________________________________________________________
________________________________________________________

CAMPUS:
CAMPUS: POS Trincity South Tobago Sangre Grande

MODE: FULL-TIME PART-TIME

Desired Start Date:

Date September January Year _________ Day Evening

Citizenship: T & T Citizen Permanent Resident Caricom International

T&T Citizens: Have you been residing in TT&T for the past three (3) Years? Yes No

If NO, length of time in Trinidad: Years ______________ Months ________________

____

Diploma/Certificate from COSTAATT? Yes

Did you earn a Degree/Diploma/
Degree/Diploma/Certificate No

Previous dates of attendance at COSTAATT: From ___/_____/_____ To ___/___/_______

/_______

Previous COSTAATT Programme _______________________________________________________________

Please
lease list any institution(s) you have attended since leaving COSTAATT:

__________________________________________________________________________________________

____________________________________________________________________________
__________________________________________________________________________________________
 2

DISABILITY DISCLOSURE:
DISCLOSURE:

Do you have a disability, chronic/long term medical condition or special need(s)? Yes No
If yes, please complete a Disability Disclosure Form. Please note that this information is required to assist
in assessing your requirements for educational provision.

NB: If you have not received a Disability Disclosure Form with this application, please contact the
Admissions Office.

EMERGENCY CONTACT:
CONTACT:
(Please complete ONLY if there has been a change since your last enrollment)

__________________________________________________________________________________________
Name Relationship Phone

__________________________________________________________________________________________
Address

DECLARATION OF APPLI
APPLICANT:
CANT:

I hereby certify that all information given on this application is accurate and complete. I understand that all
the information contained in this application will be treated confidentially and will be used for institutional
purposes only. I realize that failure to provide complete and accurate information may affect my re-
admission. I understand that my application will not be processed until all the necessary documents are
received by the Office of Admissions.

Applicant’s Signature _______________________________________ Date ____________________

FOR OFFICIAL USE ONLY

Academic Profile Reviewed by Chair. Decision:

Decision Approved for Readmission Not Approved

Comments:_________________________________________________________________________________

__________________________________________________________________________________________

Academic Chair’s Signature _____________________________________ Date ____________________

Registry Clearance Granted Yes No

Rev: 01/03/12