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For Official Use Only

ST JOHN’S UNIVERSITY OF TANZANIA
APPLICATION FORM FOR ADMISSION TO UNDERGRADUATE PROGRAMMES
To be filled in duplicate and sent to:
Office of Admissions, St John’s University of Tanzania, P.O. Box 47, Dodoma, Tanzania
(Carefully read the ‘Instructions to Applicants’ attached before filling in this application form)
Academic Year for which admission is sought (e.g. 2011/2012): ……………………………………………………….
CHOICE OF PROGRAMMES IN DESCENDING ORDER OF PREFERENCE
In the table below, enter the programmes you would like to study in descending order of preference. Details of the
degree programmes are given in the “Instructions to Applicants”.
Choice of
Programme
First Choice
Second Choice
Third Choice

Faculty/Institute/College/
Teaching Centre Code

Programme
Code

Full Name of the Programme as Indicated in the
Instruction to Applicants

1.0 PERSONAL PARTICULARS
1.1 Surname (BLOCK LETTERS): ………………………………………………………….(Mr./Mrs./Ms/Miss/Rev.)
First Name: …………………………………………………

Other Name(s)………………………………..

(Note: The names entered in this form must be exactly the same as those appearing on your A.C.S.E.E-Form VI or
C.S.E.E-Form IV certificates for applicants with equivalent qualifications)

1.2 Sex:

Male

Female

1.4 Place of Birth: ……………………………………….

1.3 Date of Birth (Attach a copy of birth certificate)
…………………………….
1.5 Citizenship: ……………………………………….

1.6 Religion:………………………………………………

1.7 Marital Status:…………………………………….

1.8 Mailing Address: …………………………………………………………………………………………………….
1.9 Telephone Number(s): ………………………………………………..

E-mail: ……………………………..

1.10 Any disability?

Hearing

None

Physical

Visual

Speech

(Note: This information is required for the University to arrange appropriate means of assisting you once admitted. It
will in no way affect the decision to admit you.)

1.11 Have you applied for admission to other Institutions?
YES
NO
If YES please list names of the Institutions:…………………………………………………………………………
………………………………………………………………………………………………………………………..
2.0 MODE OF SPONSORSHIP
Tick the appropriate box

Loan under Higher Education/Institution Loan Board

Private Sponsorship

Others (specify):………………………………………………………………………………………………...

1

Examination Authority: ………………………………………. Second Sitting Subject Grade Date Index No.. Country: ……………………………………. Examination Centre or School: ………………………………. First Sitting Subject Grade Date Index No. Second Sitting Subject Grade Date Index No.. 2 . 4...2 Advanced Certificate of Secondary Education (A. Division: …………… Points……………. ……………………………………………….E..) [National Form VI] or equivalent.) [National Form IV] or equivalent..0 EDUCATIONAL BACKGROUND AND EMPLOYMENT RECORD 4.. 4. ……………………………………………….... Examination Authority: ……………………………………….0 SPONSOR’S DECLARATION (To be completed by Private Sponsors) I hereby accept the responsibility of paying the fee and other charges for the applicant if he/she is binding Signature:………………………………………. Division: …………… Points…………….C. First Sitting Combination:…………………………………………. ………………………………………………. Subject Grade Date Index No. Examination Centre or School: ……………………………….S.E. Subject Grade Date Index No.. Division: …………… Points……………. Country: …………………………………….E. Examination Centre or School: ………………………………. Subject Grade Date Index No.S. Subject Grade Date Index No. Country: …………………………………….E.. Subject Grade Date Index No. Division: …………… Points…………….3. Examination Authority: ………………………………………...1 Certificate of Secondary Education Examinations (C.. Examination Authority: ………………………………………. Full name and address of Sponsor: Date:……………………………………………. Country: ……………………………………. Examination Centre or School: ………………………………..

Institution Attended Status (Graduated/ Discontinued/Absconded) Yes If graduated. Examination Authority: ……………………………………….2 Current position held: _______________________________________________________________________ 5. give qualification attained No Dates 4.E.S.. Diploma or Certificate.3 Contact addresses at work: (i) Telephone No. (Landline): _______________________________________________________________ (ii) Fax No: ______________________________________________________________________________ (iii) E-mail address: ________________________________________________________________________ 6. Reg.6 Employment Record Please give details of your employment record in the table below.1 Name of the Institution: _____________________________________________________________________ 5.4. provide details in the table below. S/No. University Degree. Subject Grade Date Reg./Index No.C.g. Award: ………………………………………. S/No. Name of Employer FOR POST REGISTERED NURSES ONLY Post Held Dates Mature Entrants: ADDITIONAL INFORMATION: For Application for Admission to the Undergraduate Degree in Nursing (BScN) for Post Registered Nurses (Post RNs).5 Post A-Level Education Have you attended this University/College or any other Institutions of Higher Learning before? If yes. Examination Centre or School: ………………………………. Country: …………………………………….4 In case you have submitted both types of qualifications. 5.3 Qualifications other than A./Index No. Subject Grade Date Reg.0 PROFESSIONAL QUALIFICATIONS/ACHIEVEMENTS (NURSING) Degree/Certificate Obtained Year Institution 3 . etc. Class/Grade: …………… Points…………… 4. (Form VI) or its equivalent (e..): College/Institute: ……………………………………………./Index No.0 PRESENT/ CURRENT WORK 5. which qualification do you intend to use as your primary qualification for admission? (Please tick one) A-Level Secondary Examination Equivalent (e.g.E. Diploma) Qualification 4.

shall render your registration with St John’s University of Tanzania cancelled. Note: The information given in this form will be used for admission purposes only. Decision by the SENATE: ………………………………………………………………………………………………. Date: ………………………………………… Decision by the Undergraduate Studies Committee: ……………………………………………………………………. Name of Officer: ………………………………………………………………………………………………………… Signature: ……………………………………………………. Non-disclosure of details or provision of false information to any of the sections in this form. St John’s University of Tanzania.. 4 . Signature of Applicant: ……………………………………………………… Date: ……………………………….0 APPLICATION FEE Indicate the applicant’s name as written in the bank pay-in-slip of the non-refundable Application fee: ………………………………………………………… (Note: The original pay-in-slip must be attached to this form). if discovered. Declaration I declare that all information given in this form is correct.7.0 PROFESSIONAL GOAL(S) Briefly. please state in the following space your professional goals for the next five years ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 8. FOR OFFICIAL USE ONLY Application form has been received by the Admissions Officer.

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