FICHE D'INSCRIPTION / REGISTRATION FORM 2020/2021

NB: TOUS LES CHAMPS DOIVENT ETRE OBLIGATOIREMENT REMPLIS / THE FILLING OF ALL THE FIELDS IS MANDATORY

IDENTIFICATION DU CANDIDAT ET INSCRIPTION/ CANDIDATE'S IDENTIFICATION AND REGISTRATION

Nom (s): ___________________Prénom (s) : ____________________________

Name (s) Surname(s)

Né(e) le: À: ___________________________

Born on the At

Sexe: Nationalité: ________ _______________________

Sex Citizenship

Région d'Origine: Département: Téléphone: _________________________

Region Of origin Division Telephone number

Adresse E-mail: Langue: Situation Matrimoniale: _______________________

E-mail Address Language Marrital Status

Formation: Cycle:_____________________________________ Filiere: __________________ Spécialité 1er Choix / 1st Choice

_____________________________________________
Training category Cycle Faculty Speciality
2è Choix / 2nd Choice ___________________________________________

3è Choix / 3rd Choice ___________________________________________

PROFIL SCOLAIRE ET ACADEMIQUE / ACADEMIC PROFILE

Diplôme d'admission _______________________________________________________________________________________________________________________________Mention: _________________________________________________Série ________________________________________

Admission diploma Grade Serie

Année d'obtention: ________________________________Pays d'obtention:__________________________________________________________ Etablissement

d'obtention:_______________________________________________________________________________________________________
Graduation year Graduation country Graduation school

INFORMATIONS DES PARENTS / PARENTS INFORMATION

Nom père: __________________________________________________________________________________Téléphone père: ________________________________________________________________________

Father's name Father's phone number

Nom mère: __________________________________________________________________________________Téléphone mère________________________________________________________________________

Mother's name Mother's phone number

Nom tuteur: ________________________________________________________________________________________________________________________________________________________Téléphone: ______________________

Care taker's name Care taker's phone number

AUTRES INFORMATIONS / OTHER INFORMATION

Sports: _______________________
Sports

Loisir:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_
Hobbies

Date d'inscription: ____________________________________________________________________________________Date et visa de l'étudiant: __________________________________________________________________________________________________________________________

Registration date Date and student's signature
Centre d'examen ou de dépôt de: _______________________________________________________________________________________________________________________________________________________________________________________________________________________
Examination or Filing Center