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DIRECTORATE of CONTINUING EDUCATION application form for ADMISSION INTO DIPLOMA PROGRAMMES 2014 / 2015 ACADEMIC YEAR. To be filled in duplicate and sent to: the Deputy Vice Chancellor academic Affairs, Teofilo Kisanji University, P.O. Box 1104, Mbeya, Tanzania.
DIRECTORATE of CONTINUING EDUCATION application form for ADMISSION INTO DIPLOMA PROGRAMMES 2014 / 2015 ACADEMIC YEAR. To be filled in duplicate and sent to: the Deputy Vice Chancellor academic Affairs, Teofilo Kisanji University, P.O. Box 1104, Mbeya, Tanzania.
DIRECTORATE of CONTINUING EDUCATION application form for ADMISSION INTO DIPLOMA PROGRAMMES 2014 / 2015 ACADEMIC YEAR. To be filled in duplicate and sent to: the Deputy Vice Chancellor academic Affairs, Teofilo Kisanji University, P.O. Box 1104, Mbeya, Tanzania.
FAX: +255 25 -2503721 Email: info@teku.ac.tz Web: www.teku.ac.tz TRAINING FOR BETTER LIFE
DIRECTORATE OF CONTINUING EDUCATION
APPLICATION FORM FOR ADMISSION INTO DIPLOMA PROGRAMMES 2014/2015 ACADEMIC YEAR.
To be filled in duplicate and sent to: The Deputy Vice Chancellor Academic Affairs Teofilo Kisanji University, P.O. Box 1104, Mbeya, Tanzania.
(Please read carefully the Instructions to Applicants attached before filling in this Application form)
NOTES:
i. This form should be typed or completed in BLOCK LETTERS, and returned to Deputy Vice Chancellor Academic Affairs, Teofilo Kisanji University, P .O. Box 1104 MBEYA
ii. Attach copies of (a) Current appointment letter (where applicable). (b) Certified professional and academic certificates and transcripts (c) 4 passport size photographs (d) Original up pay in slip for application fee. (e) any relevant document to support your application
iii. Attach the payment slip from the Bank for the non refundable application fee: Tshs. 30,000.00 (Thirty Thousand Tanzanian Shillings).
iv. *NO APPLICATION FORM SHALL BE PROCESSED WITHOUT AN APPLICATION FEE!
This fees should be deposited in any of the TEKU Account Numbers as follows:
S/No. Name of Bank Bank Account Number 1. NBC 016103001650 2. STANBIC 014001502028101 3. CRDB 01J1065895000 4. Commercial Bank of Africa (CBA) 0300786000 Come with pay in slip to the cashier for a University receipt.
Affix two Stamp size Photograph 2
SECTION A: PERSONAL PARTICULARS
1. Surname (Block/Capital Letters): . First Name: . Middle Names: (Note: The names entered in this form must be exactly the same as those appearing on your .C.S.E. Form IV or other certificates to be used for admission.)
2. Sex: Male Female
3. Date of Birth (Attach a copy of birth certificate):..
4. Place of Birth: .. 5. Citizenship: ..
6. Religion: .. 7. Marital Status:.
8. Postal Mailing Address:
9. Telephone Number (s)
10. E-mail:
11. 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)
NAME OF DIPLOMA PROGRAMME APPLIED FOR ...................................................................
SECTION B: ACADEMIC BACKGROUND AND EMPLOYMENT RECORD
Certificate of Secondary Education Examinations (C.S.E.E) /National Form IV/or Equivalent. S/N Subject Grade Date Index No
Examination Authority . Division
Examination Centre or School:. Country: Advanced Certificate of Secondary Education Examinations (A.C.S.E.E) /National Form VI/or Equivalent. S/N Subject Grade Date Index No
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Examination Authority . Division
Examination Centre or School:. Country:
Employment Record
Please give details of your employment record in the table below. S/N Name of Employer Post Held Dates
SECTION C: SPONSORSHIP DETAIL
1. Indicate the type of sponsorship for your studies (please tick one) Government of Tanzania Private Other (specify):
2. If you are not seeking sponsorship from the Government of Tanzania, give the full name, Address, relationship and letter of commitment from each of your sponsors.
Full name Mailing Address Tel. Numbers (s) Relationship
Sponsor 1
Sponsor 2
Sponsor 3
SECTION D: DEADLINE FOR RECEIVING OF APPLICATION FORMS.
The deadline for submission of dully filled application form is 30 th June, 2014, 16.00 pm. Application forms received thereafter (submitted in person or otherwise) shall not be processed.
SECTION E: DECLARATION I hereby declare that all information and data given in this form is correct and true to the best of my knowledge and belief. I understand that any incorrect data and information given by me will make liable to disqualification and dismissal as well as further legal action.
Also I declare that if I am admitted at Teofilo Kisanji University, I shall NOT take part in any strikes or demonstrations which will disturb the operations of the University. I hereby accept that any participation in the strikes or demonstrations shall lead me into dismissal from the University.
Signature of Applicant: . Date:
Note: The information given in this form will be used for admission purposes only. Non-disclosure of details or provision of false information to any of the sections in this form if discovered shall render your registration with the Teofilo Kisanji University cancelled. Please also submit with these forms the attached medical examination form. FOR OFFICIAL USE ONLY Application form has been received by the DOCE Admission Office Name of Officer: ...
SECTION A Past Medical History Nervous System: Any experience of loss of consciousness Yes/No-if yes, treatments
Any neurological deficiency Yes/No- if yes, treatments
Any experience of fits Yes/No if yes, treatments
Muscular-Skeletal System: Any deformity, if yes, which part of the body When acquired Current status Do use accessories or aids? If yes specify.
OTHER CHRONIC CONDITIONS: Diabetes Mellitus- if yes, when detected? What is the current status? Herpes zoster, if yes when did it happen? , What part of the body was affected? If yes when was it detected . What is the current treatment? Asthma, if yes, when was it detected and what is the current sort of treatment?
Allergies, if yes, what is the type of allergies What is its cause of reaction? Major surgeries, if yes, explain the types of surgeries. . What was the date of surgery? Do you experience any heart disease? If yes, what type and what are the current treatments?
Any dietary restrictions? If yes, state the restrictions.
I, declare that all he information provided here/in is true to the best of my knowledge
Signed date SECTION B
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To be completed by a Registered Medical Officer or Doctor
General Appearance: Height weight BLOOD PRESSURE pulse rate . Lymph node Palpable Skin appearance Throat tonsillitis teeth dentition EARS Right hearing Drum membrane . Left hearing Drum membrane Eyes, Rt va , squint. Lt. va squint CORDIO RESPIRATORY SYSTEM - Chest X-ray film and reports are needed Lung fields Breast lampus , heart size heart sounds ABDOMINAL EXAMINATION abdominal USS report is needed if mass detected film is needed Contour size- sunken/normal/distended, skin scar , umbirilicus Hernia MUSCULO SKELETAL SYSTEM Any deformation? Yes/No-if yes which part of the body? Type if deformation
BIOCHEMICAL: Fasting blood sugar Serum creatinine Serum Alanine T. Serum asoantate T Blood urea Uric acid IMMUNOLOGY VDRL reaction if +VE
treatment Widal Test if +VE treatment Contact with Human immunodeficiency virus conversation (optional)
HAEMATOLOGY-CULTURE COUNTER Haemoglobin , white cells count PARASITOLOGY Stool routine examination , treatment Urinalysis and microscopy , treatment Blood smear and sediment microscopy , treatment , Is there any other observation whether irritable aggressive
Declaration
I, Dr. , of have examined the above named candidate And conclude that the candidate is/is not it to pursue her/his studies.
Signed date
*Delete which does not apply
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TEOFILO KISANJI UNIVERSITY
Training for Better Life
DIRECTORATE OF CONTINUING EDUCATION (DOCE)
NON DEGREE PROGRAMMES
FOR 2013/2014 ACADEMIC YEAR
S/No. PROGRAMME TITLE 1. Diploma in Education 2. Diploma in Early Childhood Education 3. Diploma in Law 4. Diploma in Human Resource Management 5. Diploma in Business Administration 6. Diploma in Community Development and Social Work 7. Diploma in Information Technology 8. Diploma Accounting and Finance 9. Diploma in Procurement, Logistics and Management 10. Diploma in Journalism and Mass communication 11 Diploma in library and Information Science
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DIPLOMA TANZANIA STUDENTS (IN TANZANIA SHILLINGS) DIRECT COSTS TO THE UNIVESITY (Payable to the University)
Application fee 30,000.00 Registration fee 30,000.00 SUBTOTAL 60,000.00 Tuition fee 800,000.00 Examination fee 40,000.00 Caution Money 30,000.00 Identity Card 10,000.00 Student union 15,000.00 Training/Teaching Practice 40,000.00 TEKU Development Fund 20,000.00 SUBTOTAL 955,000.00 TOTAL 1,015,000.00 INDERECT COSTS( Incurred by the Student/Sponsor during studies)
Accommodation and meals (240 days @ Tshs.5,000.00, estimated) 1,800,000.00 Health Insurance (estimate) 100,000.00 Books and Stationery (estimated) 300,000.00 Internet Services (estimate) 50,000.00 Graduation Ceremony Purchase of graduation Gown (optional) 40,000.00 Independent Research Project (estimated) 500,000.00 Teaching Practice/field Attachment (estimated) 420,000.00 SUBTOTAL 3,160,000.00 GRAND TOTAL 4,335,000.00