Form No. 2
THE UNITED REPUBLIC OF TANZANIA
MINISTRY OF EDUCATION AND VOCATIONAL TRAINING
AGENCY FOR THE DEVELOPMENT OF EDUCATIONAL MANAGEMENT
(ADEM)-BAGAMOYO
APPLICATION FORM FOR ADMISSION INTO CERTIFICATE OF
EDUCATION LEADERSHIP, MANAGEMENT AND ADMINISTRATION
(CELMA) THROUGH OPEN AND DISTANCE LEARNING (ODL)
IN THE ACADEMIC YEAR 2014/2015
Instruction
 Read carefully form no. 1 before filling in this form
 All information should be written in capital letters
 All applications should be posted not later than the deadline indicated
PART A: PERSONAL INFORMATION
1.
Surname:……………………………… (as it appears in your certificates)
First name:…………………………………………………………………………
Middle Name………………………………………………………………………
2.
Mailing Address:
P.O. Box …………………………. Town/City…………………………………
Country………………………………. Phone…………………………….
3.
Gender:
4.
Occupation…………………………………………………………………………
5.
Name and address of employer/sponsor (if any)
Male
Female
…………………………………………………………………………………………
…………………………………………………………………………………………
6.
Citizenship: Tanzanian
Non Tanzanian
PART B: EDUCATIONAL BACKGROUND
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7. Certificate of Secondary School Examination results or equivalent
(O level)
Subject
Grade
Date
Examination Authority………………………………………………..…………….……
Index No……………………………………………………………………………………..
Examination Centre/School……………………………………. ………………………
Country………………………………………. Class awarded…………..………………
8. Teacher Training College
Subject
Grade
Date
Examination Authority……………………………………………………………………
Index No……………………………………………………………………………………..
Examination Centre ………………………………………………………………………
Country…………………………………………………………..………………………….
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9. Advanced Certificate of Secondary School Examinations results or
equivalent (in case attended)
Subject
Grade
Date
Examination Authority……………………………………………………………………
Index No……………………………………………………………………………………..
Examination Centre ………………………………………………………………………
Country……………………………………………………………………..……………….
Class awarded……………………....................................................................
10. Any other training / Qualifications…………………….……………………
……………………………………………………………….…..……………………………
………………………………………………………………………..…………………..…..
11. DECLARATION
I agree to abide by the rules and regulations of the Agency for the
Development of Education Management (ADEM). I also certify that the
information provided above is true and complete in all aspects. I
agree that: ADEM retains the right to nullify my admission if the
information provided is found to be false.

I am not under suspension or dismissal from any other
institution for reasons of academic misconduct.
Signature……………………………………………Date…………………………
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12.
PART C: TO BE FILLED BY EMPLOYER/SPONSOR
I/We(name of Council/Institution)……………………………………………..
hereby agree to allow (name of applicant)……..………………………who
is applying for Certificate in Education Leadership, Management and
Administration (CELMA).
Signature……………………………………………………………………………..
Full name and address of employer……………...…………………………….
Office phone:………………………..…………………………….…………………
Position…………………..………………………………………….………………..
……………………………………………………………………….…………………
Official Stamp…………………….................Date……………………………
ATTACHMENTS TO THE APPLICATION FORM.
i.
Copies of Secondary School Certificates.
ii.
Copy of Birth Certificate.
iii.
Copies of Academic Transcripts and Certificates.
iv.
An original receipt (Bank Pay-in-Slip of non refundable application
fees T.shs 20,000/= should be paid through the bank NMB
ADEM Revenue Account No. 21001100010.
All non-Tanzanian certificates should be translated according to NECTA
and NACTE grades before submitted for application.
Successful applicants will be required to bring the original certificates for
verification at the time of registration.
* The application should be sent not later than 30 th November, 2014
All applications should be addressed to:
Chief Executive,
ADEM,
P. O. Box 71,
BAGAMOYO.
OR
Campus Manager,
ADEM-Mwanza,
P. O. Box 1234,
MWANZA.
*You can also sent your ready filled and signed application form (with all relevant
attachments) through e-mail at:
[email protected](Bagamoyo) OR [email protected] (Mwanza).
NB: For further information call:
BAGAMOYO CAMPUS
MWANZA CAMPUS
• Fax: +255 23 2440216
Fax: +255 28 2540185
• Tel: +255 23 2440225/2440022
Tel: +255 28 2540186
*This form can be downloaded at ADEM websites:www.adem.ac.tz or
www.ademtz.com
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