Registration Form

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<!DOCTYPE html>
<!--[if lte IE 7]> <html class="ie-lte7" dir="ltr"> <![endif]-->
<!--[if lte IE 9]> <html class="ie-lte9" dir="ltr"> <![endif]-->
<!--[if !IE]><!--> <html dir="ltr">             <!--<![endif]-->
<head>
        <title>UIT Admission Form</title>
        <meta http-equiv="Content-Type" content="text/html; charset=utf-8">
        <meta name="viewport" content="width=device-width, initial-scale=1.0, maximum-scale=1.0, user-scalable=no">
        <meta name="description" content="UIT Admission Form Email Forms">
        <meta name="keywords" content="UIT Admission Form">
        <script src="//twemoji.maxcdn.com/2/twemoji.min.js"></script>
<script src="//ajax.googleapis.com/ajax/libs/dojo/1.8/dojo/dojo.js"></script>
<script type="text/javascript">
    require([
        "dojo/query",
        "dojo/dom",
        "dojo/dom-geometry",
        "dojo/dom-class",
        "dojo/dom-style",
        "dojo/dom-construct",
        "dijit/focus",
        "dojo/parser",
        "dijit/form/DateTextBox",
        "dojo/NodeList-traverse",
        "dojo/domReady!"
    ], function(query, dom, domGeom, domClass, domStyle, domConstruct, focusUtil, parser){

        // Move the focused-field class to the field-group that contains the focused input.
        var handle = focusUtil.watch("curNode", function(name, oldValue, newValue){
            var parent = query(newValue).closest('.field-group');
            if(!domClass.contains(parent, "focused-field")) {
                query('.focused-field').removeClass('focused-field');
                parent.addClass('focused-field');
            }
        });

        // Add error class to parent wrapper and only show error borders on empty fields in addresses
        query('.feedback.error').closest('.field-group').addClass('error');
        query('.addressfield input:text[value=""]').addClass('empty');

        // Focus first input of birthdayfield or phonefield-us when parent wrapper is clicked
        query('div.subfields').on("click", function(e){
            var firstInput = query('input', e.target)[0];
            focusUtil.focus(firstInput);
        });

        // Prevent image blowout in IE6 since it doesn't support max-width
        if (domClass.contains(query('html')[0], "ie-lte7")){

            query('img').forEach(function(node){
                var computedStyle = domStyle.getComputedStyle(node);
                var w = domGeom.getContentBox(node, computedStyle).w;
                console.log(w);
                if(w >= 600){
                    domStyle.set(node, "width", "600px");
                }
            });
        }

        // Use native checkboxes and radio buttons outside the app
        dojo.query(".radio input, .checkbox input").removeAttr("data-dojo-type");

        // Render DateTextBoxes
        parser.parse();

        query('form').on("submit",function(e){
            var invalidDate = dojo.query('.dijitTextBoxError');
            if(invalidDate.length){
                query('.dijitDateTextBox ~ .feedback.error').forEach(domConstruct.destroy);
                invalidDate.forEach(function(node) {
                    domConstruct.place('<div class="feedback error"><div class="errorText">Please enter a valid date</div></div>', node, 'after');
                });
                e.preventDefault();
            }
        });

        twemoji.parse(document.body, { size: 72 });

        query(".emoji").forEach(function(emoji){
            domStyle.set(emoji, {
                width: "16px",
                height: "16px"
            });
        });
    });
</script>

<script src='https://www.google.com/recaptcha/api.js' async defer></script>
<script type="text/javascript" src="https://www.google.com/jsapi"></script>

       
       
    <style type="text/css">/* Forms */

label {
    display:block;
    width:auto;
    margin-top:8px;
    font-weight:bold;
}

.mergeRow {
    padding:0 0 6px 0 !important;
    clear:both;
}

.field-group {
    position:relative;
    margin:3px 0 12px 0;
    overflow:hidden;
    background:transparent !important;
}
.mergeRow-radio .field-group, .mergeRow-interests-checkboxes .field-group {margin-bottom:6px;}

input, textarea, select {
    display:block;
    margin:0;
    padding:10px;
    background:#fff;
    width:100%;
    border:2px solid #d0d0d0 !important;
    border-radius:3px;
    -webkit-appearance: none;
}

.field-group input, select, textarea, .dijitInputField {
    font-size: 14px;
}

.field-group.error > input,
.field-group.error > select,
.field-group.error .addressfield input.empty,
.field-group.error .birthdayfield,
.field-group.error .subfields,
.field-group.error .datefield .dijitInputInner,
.datefield .dijitTextBoxError .dijitInputInner,
.field-group.error textarea {
    border-color:#e85c41 !important;
}

textarea {
    font:14px/18px 'Helvetica', Arial, sans-serif;
    width:100%;
    height:150px;
    overflow:auto;
}

select {
    background:#fff url(/images/icons/signup-sprite.png) no-repeat right -295px;
    background:#fff url(/images/icons/signup-sprite.png) no-repeat right -295px, -webkit-gradient(linear, left top, left bottom, from(#fff), to(#f1f1f1));
    background:#fff url(/images/icons/signup-sprite.png) no-repeat right -295px, -webkit-linear-gradient(top, #fff, #f1f1f1);
    background:#fff url(/images/icons/signup-sprite.png) no-repeat right -295px,     -ms-linear-gradient(top, #fff, #f1f1f1);
    background:#fff url(/images/icons/signup-sprite.png) no-repeat right -295px,         linear-gradient(to bottom, #fff, #f1f1f1);
}
html[dir="rtl"] select {background-position:14px -295px;}

/* Firefox always displays native select arrow button, so hide the background image arrow. */
@-moz-document url-prefix() {
select {
    padding: 8px;
    background-position: -99px 0 !important;
    -moz-appearance: none;
}
}

input:focus, textarea:focus, select:focus, .focused-field .subfields {
border-color:#5d5d5d !important;
outline:none;
}

/* Prevent Chrome's autofill yellow box shadow */
input:-webkit-autofill {
    -webkit-box-shadow: 0 0 0 1000px white inset !important;
}


.field-help {
    display:block;
    font-weight:normal;
    position:static;
    float:none;
    clear:both;
    margin:0;
    padding:0;
    max-height:0;
    overflow:hidden;
    -webkit-transition: all .25s;
    -moz-transition: all .25s;
    -ms-transition: all .25s;
    transition: all .25s;
}
.focused-field .field-help, input:focus + .field-help {
    display:block;
    padding:10px 0;
    max-height:100px;
}

.field-help .help {
    min-height:16px;
    text-decoration: none;
}


/* Error container */
.feedback {
    padding:10px 0;
    line-height:16px;
    font-size:14px;
}

.feedback br {display:none;}

.feedback div {
    font:14px/20px 'Helvetica', Arial, sans-serif !important;
    padding:0 !important;
    margin:0 !important;
}

.indicates-required {text-align:right;}
.indicates-required span {
    font-size:150%;
    font-weight:bold;
    display:inline !important;
}

.formstatus {
    margin-bottom:12px;
    font-size:18px;
}

.alert {
    background:#e4f3d4;
    border:2px solid #5ca000;
    font-size:14px;
    color:#4e7e0e !important;
    margin:10px 0;
    padding:10px;
}


/* Groups, checkboxes, radio buttons */
ul.interestgroup_field,
ul.interestgroup_field li,
ul.unsub-options,
ul.unsub-options li,
.interestgroup_row {
    display:block;
    padding:0;
    margin:0;
    list-style:none;
}
label.checkbox, label.radio {
    font-weight:normal;
    position:relative;
    line-height:24px;
}
.checkbox input, .radio input {
    width:auto !important;
    display:inline-block;
    margin-right:5px;
    padding:0;
    border:none;
    background-color:transparent;
}

/* Address blocks */
.addressfield span {display:block; margin:3px 0 15px 0;}
.addressfield label {display:none;}
.cityfield {width:35%; float:left; padding-right:12px;}
.statefield {width:30%; float:left; padding-right:12px;}
.zipfield {width:35%; float:left;}
.countryfield {clear:both;}

/* Date picker */
.dijitCalendarPopup {position:absolute;}
.dijitComboBox.dijitDateTextBox .dijitArrowButtonContainer {
    cursor:pointer;
    position:absolute;
    top:3px;
    right:2px;
    background:url(/images/icons/signup-sprite.png) no-repeat 10px -235px;
    height:34px;
    width:42px;
    opacity:.5;
    padding:0 5px;
}
.dijitComboBox.dijitDateTextBox .dijitArrowButtonContainer input {visibility:hidden;}
.dijitComboBox.dijitDateTextBox .dijitArrowButtonContainer:hover {opacity:1;}
.dijitValidationContainer {display:none;}

/* Input placeholder color */
.dijitPlaceHolder {position:absolute; top:10px; left:10px; color:#ababab !important; font-weight:normal;}
::-webkit-input-placeholder {color:#ababab;}
:-moz-placeholder {color:#ababab; opacity:1;}
::-moz-placeholder {color:#ababab; opacity:1;}
:-ms-input-placeholder {color:#ababab;}

html[dir="rtl"] .dijitComboBox.dijitDateTextBox .dijitArrowButtonContainer {left:6px; right:auto;}
html[dir="rtl"] .dijitPlaceHolder {left:auto; right:10px;}


/* Birthday & US phone field */
.subfields {
    display:block;
    margin:0;
    padding:8px 10px;
    background:#fff;
    width:100%;
    border:2px solid #d0d0d0;
    border-radius:3px;
    color:#d0d0d0
}
.subfields input {
    display:inline-block;
    margin:0;
    padding:0;
    width:2.5em;
    border:none !important;
    text-align:center;
}
.subfields label {display:none;}
.phonedetail2 input {width:3.4em;}
.birthdayfield input {width:1.7em;}

/* Forward to friend */
.captcha {
    float:left;
    width:320px;
    margin-right:20px;
    min-height:150px;
}
.captcha input {display:inline;}

/* Archive list */
#archive-list {
    display:block;
    margin:15px 0;
    padding:0;
    border-top:1px solid #eee;
}
#archive-list li {
    display:block;
    list-style:none;
    margin:0;
    padding:6px 10px;
    border-bottom:1px solid #eee;
}

.borderbox, .field-help, input, textarea, select {
    -moz-box-sizing: border-box;
    -webkit-box-sizing: border-box;
    box-sizing: border-box;
}

.field-shift {
    left: -9999px; position: absolute;
}

html[dir="rtl"] .field-shift {
    right: -9999px;
    left: auto;
}


/* Image replacement for checkbox and radio buttons. */
/* Placing in @media block forces browsers that don't support :checked to fall back to native inputs. */
@media only screen {
    .mergeRow-radio .field-group, .mergeRow-interests-checkboxes .field-group {margin:0 -6px 11px -6px;}

    .checkbox, .radio {
        margin:9px 0 0 0;
        padding:0;
    }

    /* Position and hide the real checkboxes and radio buttons */
    .checkbox input, .radio input {
        position:absolute;
        width:24px;
        height:24px;
        overflow:hidden;
        margin:0;
        padding:0;
        outline:0;
        opacity:0;
    }

    .checkbox input + span, .radio input + span {
        display:block;
        border-radius:3px;
        padding:6px 6px 6px 38px;
    }

    .checkbox:hover span,
    .checkbox input:focus + span,
    .radio:hover span,
    .radio input:focus + span {
        background:rgba(0,0,0,.05);
    }

    /* Insert a pseudo element inside each label with a background sprite.  */
    .checkbox input + span:before, .radio input + span:before {
        display:block;
        position:absolute;
        top:6px;
        left:6px;
        width:24px;
        height:24px;
        background:url(/images/icons/signup-sprite.png) no-repeat;
        content:" ";
        vertical-align:top;
    }

    /* Position the background sprite based on state of checkbox/radio. */
    .radio input:focus + span:before { background-position:0 -30px; }
    .radio input:checked + span:before { background-position:0 -60px; }
    .radio input:checked:focus + span:before { background-position:-0 -90px; }
    .checkbox input + span:before { background-position:0 -120px; }
    .checkbox input:focus + span:before { background-position:0 -150px; }
    .checkbox input:checked + span:before { background-position:0 -180px; }
    .checkbox input:checked:focus + span:before { background-position:0 -210px; }

    /* Right-to-left checkbox/radio modifications */
    html[dir="rtl"] .checkbox input + span:before, html[dir="rtl"] .radio input + span:before {left:auto; right:0;}
    html[dir="rtl"] .checkbox input + span, html[dir="rtl"] .radio input + span {padding:6px 38px 6px 6px;}
}

/* Use high-res sprite for retina displays */
@media (-webkit-min-device-pixel-ratio: 1.5),(min-resolution: 1.5dppx) {
    .checkbox input + span:before, .radio input + span:before, .calendar-icon {
        background-image:url(/images/icons/signup-sprite-2x.png);
        background-size: 24px;
    }
}

/* IE6 and 7 overrides */
.ie-lte7 .field-group input, .ie-lte7 .subfields {width:535px;}
.ie-lte7 .cityfield input {width:170px;}
.ie-lte7 .statefield input {width:121px;}
.ie-lte7 .zipfield input {width:170px;}
.ie-lte7 .subfields input {width:40px;}
.ie-lte7 .hidden-from-view {display:none;}
.ie-lte7 select {
    display:inline-block;
    width:560px;
}

/* IE doesn't support input placeholders until v10, show labels on addresses */
.ie-lte7 .addressfield label, .ie-lte9 .addressfield label {display:block; font-weight:normal; font-size:14px;}

/* Dijit styles for date picker */
.dijitPopup .dijitReset{margin:0;border:0;padding:0;font:inherit;line-height:normal;color:inherit;font-family:"Helvetica Neue",Helvetica,Arial,Verdana,sans-serif}
.dijitPopup .dj_a11y .dijitReset{-moz-appearance:none;}
.dijitPopup .dijitInline{display:inline-block;border:0;padding:0;vertical-align:middle}
.dijitPopup .dijitInline{display:inline-table;box-sizing:content-box;-moz-box-sizing:content-box}
.dijitPopup .dijitHidden{display:none !important}
.dijitPopup .dijitVisible{display:block !important;position:relative;}
.dijitPopup .dijitInputContainer{overflow:hidden;float:none !important;position:relative}
.dijitPopup .dj_ie .dijitSelect input,
.dijitPopup .dj_ie input.dijitTextBox,
.dijitPopup .dj_ie .dijitTextBox input{font-size:100%}
.dijitPopup .dijitSelect .dijitButtonText{float:left;vertical-align:top}
.dijitPopup .dijitSelect{padding:0 !important;}
.dijitPopup .dijitTextBox .dijitSpinnerButtonContainer,
.dijitPopup .dijitTextBox .dijitArrowButtonContainer,
.dijitPopup .dijitValidationTextBox .dijitValidationContainer{float:right;text-align:center}
.dijitPopup .dijitSelect input.dijitInputField,
.dijitPopup .dijitTextBox input.dijitInputField{padding-left:0 !important;padding-right:0 !important}
.dijitPopup .dijitValidationTextBox .dijitValidationContainer{display:none}
.dijitPopup .dijitTeeny{font-size:1px;line-height:1px}
.dijitPopup .dijitOffScreen{position:absolute !important;left:50% !important;top:-10000px !important}
.dijitPopup .dijitPositionOnly{padding:0 !important;border:0 !important;background-color:transparent !important;background-image:none !important;height:auto !important;width:auto !important}
.dijitPopup .dijitNonPositionOnly{float:none !important;position:static !important;margin:0 0 0 0 !important;vertical-align:middle !important}
.dijitPopup .dijitBackgroundIframe{position:absolute;left:0;top:0;width:100%;height:100%;z-index:-1;border:0;padding:0;margin:0}
.dijitPopup .dijitDisplayNone{display:none !important}
.dijitPopup .dijitContainer{overflow:hidden;}

.dijitPopup{position:absolute;background-color:transparent;margin:0;border:0;padding:0}
.dijitPopup{-webkit-box-shadow:0 6px 6px 1px rgba(0, 0, 0, 0.1);box-shadow:0 6px 6px 1px rgba(0, 0, 0, 0.1);border-radius:6px}
@media screen and (max-width:40em){
    .dijitPopup{width:96% !important;left:50% !important;margin:0 auto 0 -48%}
}
.dijitPopup .dijitMenuTable{width:100% !important}

.dijitMenu{border:1px solid #000;background-color:#fff}
.dijitMenuTable{border-collapse:collapse;border-width:0;background-color:#fff}
.dj_webkit .dijitMenuTable td[colspan="2"]{border-right:hidden}
.dijitMenuItem{text-align:left;white-space:nowrap;padding:.1em .2em;cursor:pointer}
.dijitMenuItem:focus{outline:none}
.dijitMenuItemIcon,
.dijitMenuExpand{background-repeat:no-repeat}
.dijitMenuItemDisabled *{opacity:.5;cursor:default}
.dj_ie .dj_a11y .dijitMenuItemDisabled,
.dj_ie .dj_a11y .dijitMenuItemDisabled *,
.dj_ie .dijitMenuItemDisabled *{color:#808080;filter:alpha(opacity=35)}
.dijitMenuItemLabel{position:relative;vertical-align:middle}
.dj_a11y .dijitMenuItemSelected{border:1px dotted #000 !important;}
.dj_ff3 .dj_a11y .dijitMenuItem td{padding:0 !important;background:none !important}
.dj_a11y .dijitMenuItemSelected .dijitMenuItemLabel{border-width:1px;border-style:solid}
.dj_ie8 .dj_a11y .dijitMenuItemLabel{position:static}
.dijitMenuExpandA11y{display:none}
.dj_a11y .dijitMenuExpandA11y{display:inline}
.dijitMenuSeparator td{border:0;padding:0}
.dijitMenuSeparatorTop{height:50%;margin:0;margin-top:3px;font-size:1px}
.dijitMenuSeparatorBottom{height:50%;margin:0;margin-bottom:3px;font-size:1px}
.dijitCheckedMenuItemIconChar{vertical-align:middle;visibility:hidden}
.dijitCheckedMenuItemChecked .dijitCheckedMenuItemIconChar{visibility:visible}
.dj_a11y .dijitCheckedMenuItemIconChar{display:inline !important}
.dj_a11y .dijitCheckedMenuItemIcon{display:none}
.dj_ie .dj_a11y .dijitMenuBar .dijitMenuItem{margin:0}



.dijitCalendarContainer{width:auto;}
.dijitCalendarContainer th,
.dijitCalendarContainer td{padding:0;vertical-align:middle}
.dijitCalendarYearLabel{white-space:nowrap;}
.dijitCalendarNextYear{margin:0 0 0 .55em}
.dijitCalendarPreviousYear{margin:0 .55em 0 0}
.dijitCalendarIncrementControl{vertical-align:middle}
.dijitCalendarIncrementControl,
.dijitCalendarDateTemplate,
.dijitCalendarMonthLabel,
.dijitCalendarPreviousYear,
.dijitCalendarNextYear{cursor:pointer}
.dijitCalendarDisabledDate{color:#808080;text-decoration:line-through;cursor:default}
.dijitSpacer{position:relative;height:1px;overflow:hidden;visibility:hidden}
.dijitCalendarMonthMenu .dijitCalendarMonthLabel{text-align:center}

.dijitCalendar{border:solid 1px #cfcfcf;background-color:#fff;text-align:center;padding:18px;border-radius:6px;border-collapse:separate}
.dijitCalendar img{border:none}
.dijitCalendarMonthContainer th{text-align:center;vertical-align:middle}
.dijitCalendarMonthLabel{color:#595959;font-size:.9375em;font-weight:bold;padding:6px 12px}
.dijitA11ySideArrow{display:none}

.dijitCalendarArrow{cursor:pointer;border:1px solid transparent;position:relative;}
.dijitCalendarArrow img {display:none;}
.dijitCalendarArrow:hover{background-color:#f2f2f2;border-color:#d0d0d0}
.dijitCalendarArrow:after{content:" "; width:0; height:0; border:6px solid transparent; border-left:6px solid #333; display:block; position:absolute; top:25%; left:45%}
.dijitCalendarArrow:first-child:before{content:" "; width:0; height:0; border:6px solid transparent; border-right:6px solid #333; display:block; position:absolute; top:25%; left:45%}
.dijitCalendarArrow:first-child:after{border:none;}

.dijitCalendarCurrentDate {background:#eee;}
.dijitCalendarDayLabelTemplate{text-align:center;font-weight:bold;padding:8px 12px}
.dijitCalendarDayLabel{font-weight:bold;font-size:.9375em;text-align:center;color:#595959}
.dijitCalendarDateTemplate{border-bottom:0 none;font-size:.9375em;font-weight:500;letter-spacing:.05em;text-align:center;color:#595959}
.dijitCalendarPreviousMonth,
.dijitCalendarNextMonth{border-bottom:0 none}
.dijitCalendarDateTemplate .dijitCalendarDateLabel{text-decoration:none;display:block;padding:6px 10px;border:1px solid transparent;-webkit-transition-property:background-color,border;-ms-transition-property:background-color,border;transition-property:background-color,border;-webkit-transition-duration:.35s;-ms-transition-duration:.35s;transition-duration:.35s}
.dijitCalendarPreviousMonth .dijitCalendarDateLabel,
.dijitCalendarNextMonth .dijitCalendarDateLabel{color:#ababab;border-color:#fff;}
.dijitCalendarYearContainer{vertical-align:middle}
.dijitCalendarYearControl{padding:1px 2px 2px 2px}
.dijitCalendarYearLabel{padding:8px 0 0;margin:0;font-size:.9375em}
.dijitCalendarYearLabel span{vertical-align:middle}
.dijitCalendarSelectedYear{padding:0 6px;font-size:.9375em;color:#52bad5}
.dijitCalendarNextYear,
.dijitCalendarPreviousYear{font-size:.9375em;border:1px solid transparent;padding:6px 12px}
.dijitCalendarHoveredDate .dijitCalendarDateLabel,
.dijitCalendarEnabledDate:hover .dijitCalendarDateLabel{background-color:#b1e0ec;border:solid 1px #52bad5;color:#595959;-webkit-transition-duration:.2s;-ms-transition-duration:.2s;transition-duration:.2s}
.dijitCalendarNextYearHover,
.dijitCalendarNextYear:hover,
.dijitCalendarPreviousYearHover,
.dijitCalendarPreviousYear:hover{color:#595959;background-color:#f2f2f2;border-color:#d0d0d0}
.dijitCalendarNextYearActive,
.dijitCalendarNextYear:active .dijitCalendarPreviousYearActive,
.dijitCalendarPreviousYear:active{background-color:#c7c7c7}
.dijitCalendarActiveDate .dijitCalendarDateLabel,
.dijitCalendarEnabledDate:active .dijitCalendarDateLabel{border:solid 1px #fff;-webkit-transition-duration:.1s;-ms-transition-duration:.1s;transition-duration:.1s}
.dijitCalendarSelectedDate .dijitCalendarDateLabel{color:#595959;background-color:#b1e0ec;border:solid 1px #52bad5}
.dijitCalendarDisabledDate .dijitCalendarDateLabel{color:#808080;text-decoration:line-through}
.dijitCalendar .dijitDropDownButton{margin:0;background-color:transparent}
.dijitCalendar .dijitDropDownButtonHover .dijitButtonNode,
.dijitCalendar .dijitDropDownButton:hover .dijitButtonNode{background-color:transparent;border:0 none}
.dijitCalendarMonthMenu{border-color:#ababab;background-color:#fff;text-align:center;background-image:none}
.dijitCalendarMonthMenu .dijitCalendarMonthLabel{border-top:solid 1px transparent;border-bottom:solid 1px transparent}
.dijitCalendarMonthMenu .dijitCalendarMonthLabelHover,
.dijitCalendarMonthMenu .dijitCalendarMonthLabel:hover{background-color:#b1e0ec;border-color:#52bad5;border-width:1px 0}

.dijitTooltip{display:none !important;}

</style><style type="text/css">
        body{
            font:14px/20px 'Helvetica', Arial, sans-serif;
            margin:0;
            padding:75px 0 0 0;
            text-align:center;
            -webkit-text-size-adjust:none;
        }
        p{
            padding:0 0 10px 0;
        }
        h1 img{
            max-width:100%;
            height:auto !important;
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    <body>

        <div class="wrapper rounded6" id="templateContainer">
            <h1 class="masthead">Apply For Guaranteed Admission Into Unival Institute Of Technology (UIT), Benin City.<br>
<br>
UIT was adjudged 3rd Most Selected IEI 2016/2017 session by JAMB<br>
&nbsp;</h1>

            <div id="templateBody" class="bodyContent rounded6">
   
       
       
       
       
        <div id="subscribeFormWelcome"><h1 class="masthead"><img data-file-id="3326185" height="296" src="https://gallery.mailchimp.com/8e28bc6b84566fcab0e9a0e6f/images/9011818f-496e-47dc-a34d-fda5f1824c30.jpg" style="border: 0px  ; width: 661px; height: 296px; margin: 0px;" width="661"></h1>

<div id="tpl-image-content-header_image">Please Fill The Form Below And Our Admission Officer Will Contact you Shortly.</div>
</div>
<div class="indicates-required"><span class="asterisk">*</span> indicates required</div>



<form action="https://uitbenin.us10.list-manage.com/subscribe/post" method="POST">
    <input type="hidden" name="u" value="8e28bc6b84566fcab0e9a0e6f">
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        <input type="text" name="b_name" tabindex="-1" value="" placeholder="Freddie" id="b_name">

        <label for="b_email">Email: </label>
        <input type="email" name="b_email" tabindex="-1" value="" placeholder=" This email address is being protected from spambots. You need JavaScript enabled to view it. " id="b_email">

        <label for="b_comment">Comment: </label>
        <textarea name="b_comment" tabindex="-1" placeholder="Please comment" id="b_comment"></textarea>
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            <label for="MERGE5">Phone Number <span class="req asterisk">*</span></label>
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                <div class="field-help">Type Your GSM number here</div>
               
               
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            <label for="MERGE0">Email Address <span class="req asterisk">*</span></label>
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            <label for="MERGE7">Gender</label>
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        <div class="mergeRow dojoDndItem mergeRow-radio" id="mergeRow-6">
            <label for="MERGE6">Have You Taken JAMB Exam? <span class="req asterisk">*</span></label>
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                <div class="interestgroup_field radio-group" id="MERGE6"> <label class="radio" for="MERGE6-0"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE6" id="MERGE6-0" value="I did JAMB Exam This Year"  class="av-radio"><span>I did JAMB Exam This Year</span></label><label class="radio" for="MERGE6-1"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE6" id="MERGE6-1" value="I did JAMB Last Year or Years Back"  class="av-radio"><span>I did JAMB Last Year or Years Back</span></label><label class="radio" for="MERGE6-2"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE6" id="MERGE6-2" value="I Have Never Done JAMB"  class="av-radio"><span>I Have Never Done JAMB</span></label> </div>


               
               
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                <div class="interestgroup_field radio-group" id="MERGE8"> <label class="radio" for="MERGE8-0"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE8" id="MERGE8-0" value="Computer Science"  class="av-radio"><span>Computer Science</span></label><label class="radio" for="MERGE8-1"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE8" id="MERGE8-1" value="Computer Software Engineering"  class="av-radio"><span>Computer Software Engineering</span></label><label class="radio" for="MERGE8-2"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE8" id="MERGE8-2" value="Computer Hardware Engineering"  class="av-radio"><span>Computer Hardware Engineering</span></label><label class="radio" for="MERGE8-3"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE8" id="MERGE8-3" value="Accountancy"  class="av-radio"><span>Accountancy</span></label><label class="radio" for="MERGE8-4"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE8" id="MERGE8-4" value="Business Administration"  class="av-radio"><span>Business Administration</span></label><label class="radio" for="MERGE8-5"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE8" id="MERGE8-5" value="Marketing"  class="av-radio"><span>Marketing</span></label><label class="radio" for="MERGE8-6"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE8" id="MERGE8-6" value="Office Technology"  class="av-radio"><span>Office Technology</span></label><label class="radio" for="MERGE8-7"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE8" id="MERGE8-7" value="Hospitality Management"  class="av-radio"><span>Hospitality Management</span></label><label class="radio" for="MERGE8-8"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE8" id="MERGE8-8" value="Paralegal Studies"  class="av-radio"><span>Paralegal Studies</span></label><label class="radio" for="MERGE8-9"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE8" id="MERGE8-9" value="Library and Information Science"  class="av-radio"><span>Library and Information Science</span></label><label class="radio" for="MERGE8-10"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE8" id="MERGE8-10" value="Performing and Media Arts"  class="av-radio"><span>Performing and Media Arts</span></label><label class="radio" for="MERGE8-11"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE8" id="MERGE8-11" value="Cosmetology and Beauty"  class="av-radio"><span>Cosmetology and Beauty</span></label> </div>


               
               
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        <div class="mergeRow dojoDndItem mergeRow-radio" id="mergeRow-9">
            <label for="MERGE9">What is Your WAEC/NECO/GCE Result Status? <span class="req asterisk">*</span></label>
            <div class="field-group">
                <div class="interestgroup_field radio-group" id="MERGE9"> <label class="radio" for="MERGE9-0"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE9" id="MERGE9-0" value="I have 5 Credits in WAEC/NECO/GCE/Others"  class="av-radio"><span>I have 5 Credits in WAEC/NECO/GCE/Others</span></label><label class="radio" for="MERGE9-1"><input type="radio" data-dojo-type="dijit/form/RadioButton" name="MERGE9" id="MERGE9-1" value="Awaiting Results"  class="av-radio"><span>Awaiting Results</span></label> </div>


               
               
            </div>
           
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        <div class="mergeRow dojoDndItem mergeRow-text" id="mergeRow-3">
            <label for="MERGE3">Do You Have A question?</label>
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                <input type="text" name="MERGE3" id="MERGE3" size="25" value="">
               
                <div class="field-help">You can ask any question here</div>
               
               
            </div>
           
        </div>
       
       


       

       

       
    </div>

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        <input type="submit" class="formEmailButton" name="submit" value="Click To Register">
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