ARCHBISHOP JAMES UNIVERSITY COLLEGE
(AJUCO)
(A Constituent College of St. Augustine University of Tanzania)
P. O. Box 466 SONGEA,
TANZANIA,
EAST AFRICA
Mobile no: 0766 11 12 13 Tel: 025 260 2862, Fax 025 260 2861,
Email: [email protected], website: www.ajuco.ac.tz
APPLICATION FORM FOR
ADMISSION ACADEMIC YEAR
2015/2016
Note: Please use block letters
PART A
PERSONAL PARTICULARS OF THE APPLICANT
1. Surname:……………………………………………………………………
First Name………………………………………………………………….
Middle name……………………………………………………………….
Note: Names and initials entered in this form must be exactly the same as those
appearing on your form four, form six and other Academic Certificates
2. Sex
(
) Female
( ) Male
3. Postal Address:………………………………………………………..
4. Mobile:…………………......................................
Fax:………………………………………………
E-mail……………………………………………..
5. Office Tel:................................................................
6. Marital Status…………………………………..Residence
Tel:..........................................
7. Date of
Birth……………………………………Nationality……………………………….........
8. Profession…………………………………………………………………………………
9. Father’s name:………………………………Occupation………………………………
10. Mother’s name:……………………………..Occupation……………………………….
11. Do you have any kind of disability?
( ) Yes ( ) No
If yes, please specify……………………………………………………………………….
Note: This information will not affect the decision to admit you; will instead help the
University in arranging appropriate means of assisting you once admitted.
FOR EMERGENCIES: Person to be contacted
Full name:…………………………………………………………………………………………
Relationship:………………………………………………………………………………………
Address:……………………………………………………………………………………...........
Telephone:………………………...Fax:…………………………….E-mail……………………
PART B
ACADEMIC BACKGROUND
Please, list schools you have attended
SEC. SCHOOLS
ATTENDED
LOCATION
DATES FROM
(MO/YR)
TO (MO/YR)
CERT. INDEX No
Please list all Colleges you have attended
S/N
INSTITUTION
STATUS(GRADUATED/
DISCONTINUED/ABSCONDED)
IF GRADUATED GIVETHE
QUALIFICATION
ATTAINED
DATES
PART D
PROGRAMME APPLIED FOR
PROGRAMME CODE
MD
FULL NAME OF THE PROGRAMME
DOCTOR OF MEDICINE
PART E
LANGUAGE FLUENCY
LANGUAGE
SPOKEN
Fair
Good
WRITTEN
Very Good
Archbishop James University College Application forms 2015/2016
PART F
REFEREES
Name and address of two referees who know your ability as a student and can assess your
competence in written and spoken English.
Full name:…………………………………………………………………………………..
Address:……………………………………………………………………………………
Full Name:…………………………………………………………………………………
Address:……………………………………………………………………………………
SPONSORSHIP
The sponsor should indicate here that the candidate would receive financial support for he/she
will spend at AJUCO
Name of Sponsor:………………………………………………………………………………
Address:………………………………………………..Tel:…………………………………..
Business/Activity………………………………………Fax/E-mail:…………………………..
I……………………………………………………….confirm that my organization will give full
financial support to……………………………………………..during the period of his/her
studies at Ajuco University College if she/he will be admitted.
Date…………………………………………Signed……………………………………………
Official Stamp/Seal
DECLARATION
I declare that all information given in this form is correct.
Signature of the Applicant………………………………Date………………………………..
PAYMENTS
Your non-refundable application fee of Tsh. 30,000/= or US $ 30 should be paid to Archbishop
James University College CRDB BANK. Account Number 0150085128519.No any other type
of payment is accepted.
Archbishop James University College. Application forms 2015/2016
ATTACHMENT
Please include the following with this application:
a) A medical Doctor’s Certificate stating that you are fit to follow this course
b) Two (2) passport-size photos of yourself (Colored)
c) A short story of your life in English (500-750 words or two foolscap) in your own
handwriting, describing the important details of your life, reasons for pursuing this course
of studies, and your plans for the future.
d) Photocopies of your school certificates or result slip (Form IV, Form VI and College if
any)
e) Birth Certificate.
f) Original Pay slip of Tshs 30,000/= (For Tanzania) or Us $ 30 (For Non Tanzanian)
When you have attached all the required materials including certification of sponsorship,
kindly send this through EMS to the Admissions Office, Ajuco University College, P.O
BOX 466, Songea.
……………………………………………………………………………………………
FOR OFFICIAL USE ONLY
Archbishop James University Application forms 2015/2016