THE UNITED REPUBLIC OF TANZANIA MINISTRY OF HEALTH COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND CHILDREN HEALTH LABORATORY PRACTITIONERS’ COUNCIL PARTI APPLICATION FOR COUNCIL'S EXAMINATIONS, FILL IN BLOCK LETTERS 1 Person particulars (a) Sumame .. petet (6) Other names... ARAN CEL” (c) Date of birth..... WA... 25.5. Vag (@) Nationality... LAN ZANT ANS (©) Present address in Tanzania wes Ha (8) Mobile number. (g) Email addres: ace: cee gona Conn, Registration sty: provide your Provisions Registration number 40.624. Employment status: Employed [Not employed (I employed provide the name and address of the employer) Nek... .ecnetexedt Moet Me. 26H (imumed Qualification (e.g. Certificate in Medical laboratory) amo’ Designation (e.g. Lab Assistant) «oul A9B.....285. ESOT Internship site (If applicable) Number of Examination attempts (e.g. 1) /, repeat Theory[ Practical| Both AAUITE 002845 If more than 1 attempt sp Control number used for payment (e.g. 991750014056) Particular of registration outside Tanzania: a. Place b. Registered by acti c. Registration number............ Registration Date... Scanned with CamScanner‘mpc_Fo2 7. Solvet two examination centre from the following list according to your preference; (Dar es Salaam, Mbeya, Mwanza, Kilimanjaro, Dodoma) a LGU RAN See >» .BeSems.. Note: Council has final mandate to the choice you made Erb, Signature of applicant walt Date NB: 1. Non-refimdable application fee (TShs.150, 000/= for Ordinary Diploma and Certificates) (Ishs, 200,000/= for Bachelor Degree), (USD 300.00 for Non ~ Tanzanian) the examination fee shall be paid through the provided control number from Health Laboratory Practitioners’ Council. This form shall be completed by applicant and sent with copies of certified provisic registration, wo passport-size photos (background light-bluc) taken within six months, and the evidence of paid examination fee (e.g. bank pay in slip) to: iF ional Health Laboratory Practitioners Council (HLPC). PO Box 743, Dodoma. OR 2. Kimail to: hpewalia vote or hlpe201Xe yahoo.com PART IL DECISION OF THE COUNCIL 1. This application has been approved/rejected by the Council 2. This application has been rejected by the Education Committee of Council which met on _ due to the following reason(s); Registrar's Signature Date SXAM APPLICATION FORM VER: 1.0 FED 2017 Page 2 of 2 @uce Pl rH PC EXAM APPLICATION FORM VER: 1.0 aa Scanned with CamScannerTHE UNITED REPUBLIC OF TANZANIA OFFICE OF THE REGISTRAR, P. 0 BOX 9083, DAR ES SALAAM, 43 November 2020 HEALTH LABORATORY PRACTITIONERS COUNCIL The Health Laboratory Practitioners Act, 2007 (CAP 48/2007) CERTIFICATE OF PROVISIONAL REGISTRATION AS A HEALTH LABORATORY PRACTITIONER i nereby certify thatthe folowing is true extract from the Register relating to registered Health Laboratory Practitioner named below: FULL NAME SEX ADDRESS QUALIFICATION’| TRAINING DATE OF EXPIRY INSTITUTION | _. REGISTRATION. DATE EMMANUEL PETER BOX 65001 munas, | 12 NOVEMBER 2020 | 12 NOVEMBER 2021 DAR ES SALAAM |, i NOTE: This cbrtficate is given lo afford immediate evidence to the registration which it attests: In due course the name of the Practitioners will appear in the list of Registered Practitioners published annually by the Health Laboratory Practitioners Council and reference should be made to the Current Published | List of the evidence of the continued registration of the Practitioner ry REGISTRAR Scanned with CamScannerAGENT ID: 427524\ TRAN NUM: LO1AGG2212881881 | REF NO: ECLOL081127554 BILL PAYMENT GEPG PAYMENT SUCCESSFUL Name: EMMANUEL PETER Control No : 991750023994 Provider: Health Laboratory Practitioners Council] Bill Desc: BMLS EXAM FEE KCMC Bill paid(Principal): 200,000.00 GEPG PAYMENT SUCCESSFUL Name: EMMANUEL PETER Control No : 991750023994 provider: Health Laboratory practitioners CounctT Bil] Desc: BMLS EXAM FEE KCMC Scanned with CamScannerScanned with CamScanner