Application Form – Nursing Company Application ID * This ID was sent to you via SMS or Email Title Choose One Mr. Ms. Mrs. First Name * Last Name * Other Name(s) Date of Birth * Mobile No * Email Address * Gender Male Female Nationality * Ghanaian Non Ghanaian Region * Ashanti Region Bono Region Bono East Region Ahafo Region Greater Accra Region Central Region Eastern Region Northern Region Savanna Region Upper East Region Upper West Region Volta Regoin Oti Region Western-North Western District * Religious Denomination * Islam Christianity Non Religious Others Home Town * Residential Address Digital Address Postal Address * Last school attended Name of School Contact Address English (Core) Enter grade obtained in the space provided Mathematics (Core) Enter grade obtained in the space provided Integrated Science Enter grade obtained in the space provided Social Studies Enter grade obtained in the space provided Elective Subject 1 Enter name of subject and grade obtained Elective Subject 2 Enter name of subject and grade obtained Elective Subject 3 Enter name of subject and grade obtained Elective Subject 4 Enter name of subject and grade obtained Elective Subject 5 Enter name of subject and grade obtained Parent/Guardian Information Father Information Name Mobile Number Occupation Permanent Address Mother Information Name Mobile Number Occupation Permanent Address Other Key Information Are you physically challenged? * No YES Do you have health related issue(s)? * No YES Accommodation Type * Day Hostel Select Course in which admission is sought * Certificate in HealthCare Nursing Certificate in Medical Laboratory Technician Diploma in Pharmacy Technology Diploma in Health Information Management Diploma in Medical Laboratory Technology Final Stage Declaration I certify that the information provided above is valid and will be help personally for its authenticity and will bear any consequences for any invalid information provided. https://mlkhealthinstitute.edu.gh/agreement/ *
