For Offial Use Only Affix tw o stamp size photographs MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES APPLICATION FORM FOR SECOND SELECTION TO ORDINARY DIPLOMA PROGRAMMES FOR THE ACADEMIC YEAR 2014/2015 EVENING OR EXECUTIVE TRACK EVENING OR EXECUTIVE TRACK Three filled copies of this form together with copies of school certificates be sent to: Director, Undergraduate Education/Admissions Office, P.O. Box 65001, Dar es Salaam, Tanzania: [email protected] (Please read carefully the Instructions to Applicants attached before filling in this application form) CHOICE OF PROGRAMMES IN DESCENDING ORDER OF PREFERENCE In the table below, enter the programmes you would like to study in order of preference. Details of the programmes are given in the Instructions to Applicants. Choice Programme Full Name of Programme Specialization (when Code applicable) First Choice Second Choice Third Choice 1.0 1.1 1.2 1.4 1.6 1.8 1.9 1.10 PERSONAL PARTICULARS Surname (Block Letters): ...................................................................................................................................... First Name: …………………………………..……… Middle Names: ..................................................... (Note: The names entered in this form must be exactly the same as those appearing on your A.C.S.E.E.Form VI or other certificates to be used for admission.) Sex: Male [ ] Female [ ] 1.3 Date of Birth: ................................................................... Place of Birth………………………… 1.5 Citizenship: ……………………………….…………………. Religion: …………………………….. 1.7 Marital Status: .................................................................. Mailing Address: P.O. Box…………………………………………………………………………………...……..…………. Telephone Number(s): .............................................. e-mail: .................................................................................... Do you have any kind of disability? Yes: [ ] No: [ ] If yes, specify………………………………………….. (Note: This Information is required in order for the University to arrange appropriate means of assisting you once admitted. It will in no way affect the decision to admit you) 2.0 2.1 EDUCATION BACKGROUND AND EMPLOYMENT RECORD Certificate of Secondary Education Examinations (C.S.E.E.)/National Form IV/or Equivalent. Subject Grade Year Index No Subject Grade Year Examination Authority ................................................................. Examination Centre or School: ..................................................... Index No Division: .................................................................... Country: .................................................................. Address of the School you attended last: Tel. No:…………………………………….email address…………………….…… Postal Address……………………………………………………………………………………………………………………………... 2.2 Advanced Certificate of Secondary Education (A.C.S.E.E.)/National Form VI or equivalent. Subject Grade Year Index No Subject Grade Year Examination Authority ................................................................... Examination Centre or School: ....................................................... Index No Division: .................................................................. Country: ................................................................. Address of the School you attended last: Tel. No:…………………………………….email address…………………….…… Postal Address…………………………………………………………………………………………... MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES Admissions Office, P.O. Box 65001, Dar es Salaam, Tanzania Instructions to applicants seeking admission to Ordinary Diploma in Evening or Executive Track Applicants are required to read these instructions carefully before filling in the application forms. Incorrectly filled or incomplete application forms will not be processed. 1.0 APPLICATION FEES Submission of duly filled application forms should be accompanied with payment of non-refundable Application fee. The application fee for Tanzanians is TShs. 20,000/= and for non-Tanzanians is USD 30. All payments should be deposited into the MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES, NATIONAL MICROFINANCE BANK OF TANZANIA LIMITED (NMB) ACCOUNT NUMBER 2091100002 (MUHIMBILI BRANCH). Remember to use the applicant’s name and make sure that you attach to your application forms a copy of our receipt which you will obtain at our Bursar’s office after presentation to him the original pay-in slip of the application fee. Applicants are advised to keep a copy of the receipt and pay-in slip for future use whenever required. 2.0 ORDINARY DIPLOMA PROGRAMMES The programme offered by MUHAS under Ordinary Diploma Executive Track includes; 1. DIPLOMA IN MEDICAL LABORATORY SCIENCES (3 YEARS) 2. DIPLOMA IN ENVIRONMENTAL HEALTH SCIENCES (3 YEARS) 3. DIPLOMA IN DIAGNOSTIC RADIOGRAPHY (3 YEARS) 4. DIPLOMA IN PHARMACEUTICAL SCIENCES (3 YEARS) 5. DIPLOMA IN NURSING (3 YEARS) 3.0 SUBMISSION OF APPLICATION FORMS Duly filled application forms should be handed in to the Admissions Office, Muhimbili University. Application forms may also be posted to: Director, Undergraduate Education, Admissions Officer, P.O. Box 65001, Dar es Salaam, Tanzania. The deadline for submission of duly filled application forms is 4 p.m. on Friday 31st October, 2014. Application forms received thereafter (whether submitted in person or otherwise) shall not be processed. 4.0 WARNING It should be noted that it is an offence to submit false information when applying for admission. Applicants who will be discovered to have submitted forged certificates or any other such information will not be considered and appropriate legal action will be taken against them. Bonafide University students are cautioned not to attempt applying for admission. If such students submit their applications then they will be liable to de-registration from studies. Likewise, former students who have already graduated cannot be admitted as undergraduate students under Government loan sponsorship. 5.0 FINAL CHECKLIST OF APPLICATION FOR ADMISSION Since incomplete application forms will not be processed, it is important that the applicant checks whether three sets of application forms are made and all the items indicated below are included in her/his application submission. (i) (ii) (iii) (iv) (v) (vi) Four stamp size black and white photographs with applicant’s name written at the back Three copies of certificates and/or result slips for O-Level or equivalent Three copies of certificates and/or result slips for A-Level or equivalent Three copies of Birth Certificate and/or Affidavit The original bank pay-in slip for the payment of the non-refundable Application fees. A letter of commitment from your sponsors indicating his/her commitment on paying the required fees and other related payment to the University N.B Accommodation facilities will not be provided to all Executive track programme. The successfully selected candidates will have to make their own accommodation arrangements.