TANZANIA CHAMBER OF

COMMERCE, INDUSTRY AND

AGRICULTURE

FOMU YA KUOMBA UONGOZI

(NOMINATION FORM)

FOMU NO.1

EC- TCCIA/MWANZA

IJAZWE NA MGOMBEA WA NAFASI YA UONGOZI WA TCCIA WILAYA

To be completed by TCCIA Wilaya leadership aspirant (Herufi kubwa ichapwe /print)

A. TAARIFA BINAFSI (Personal Details):

1. NAFASI UNAYOGOMBEA ……………………………………………………………………………….
Post aspired for
2. JINA LA MGOMBEA KWA KIREFU ………………………………………………………………………………
Name of aspired in full
3. CHEO/DESIGNATION
………………………………………………………………………………
4. TAREHE NA MAHALI ULIPOZALIWA ……………………………………………………………………………
DATE OF BIRTH AND PLACE OF BIRTH
(ambatanisha nakala ya aidha cheti cha kuzaliwa, kitambulisho cha taifa au kadi ya
Mpiga kura
(attach copy of either Birth Certificate or Passport National ID or vote ID)
5. NAMBA YA SIMU ………………………………………………………………………….
Telephone no.
6. BARUA PEPE …………………………………………………………………………..
Email
7. NAMBA YA FAX …………………………………………………………………………..
Fax no.
8. KIWANGO CHA ELIMU /TAALUMA ……………………………………………………………………………
 The academic achievement
Ambatanisha nakala ya vyeti
(Attach copy of Certificate)

9. TAJA KAMA UMEWAHI KUSHITAKIWA NA MAHAKAMA NA KUPATIKANA NA

HATIA………………………………………………………………………………………………………………………..

State if you have been charged for criminal offence and convicted

TAJA KOSA NA ADHABU ULIYOPEWA ……………………………………………………………………….

Mention offence and the santence

B. TAARIFA ZA BIASHARA /SHUGHULI/BUSINESS PARTICULARS

10. WASIFU WA BIASHARA YAKO
Your business profile
i. JINA LA KAMPUNI /BIASHARA :
Name of your Company/Business ………………………………………………………………………..
ii. AINA YA BIASHARA
Type of business ……………………………………………………………………………………………….
iii. NAMBA YA USAJILI WA KAMPUNI/BIASHARA (Ambatanisha Nakala)
Registration Number – Attach Copy ……………………………………………………………..
iv. LESENI YA BIASHARA (Ambatanisha Nakala) ……………………………………………………….
Business Lisence (Attach copy)
v. TIN /VAT (Ambatanisha nakala) …………………………………………………………………………
vi. RIPOTI YA MKAGUZI WA MAHESABU (katika kipindi cha miaka miwili iliyopita)
Attach copy of Audited Accounts for the past two years ……………………………………
vii. MAHALI ILIPO BIASHARA /SHUGHULI ………………………………………………………………….

C. TAARIFA ZA UZOEFU WA UONGOZI /Biashara (Leadership Experience)

11. TAJA NAFASI ULIZOONGOZA KATIKA BIASHARA
State the past that you have held in Business
12. (i) TOA HISTORIA YAKO KWA UFUPI KWENYE UONGOZI
Give your short back ground in leadership
Unaweza kuongeza karatasi moja /you may add additional paper
(ii) KAMA UKICHAGULIWA TAJA MIPANGO AU MTAZAMO WAKO KATIKA UONGOZI
WA TCCIA
Give your plans or opinion on administration of TCCIA if you are elected
(unaweza kuongeza karatasi moja/you may add one additional paper)
13. YAKINISHI /UTHIBITISHO
Nashuhudia /Nathibitisha kwamba yote niliyoeleza hapo juu ni kweli kabisa na
ninaweza kushitakiwa au kuwajibika iwapo itadhihirika vinginevyo.

CERTIFICATION /CONFIRMATION
I here by certify/verify that all what I have stated above is true and I may be
prosecuted or held responsible if the above proved otherwise.

SAHIHI YA MGOMBEA

Signature of aspirant _______________ Muhuri _________________________