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Application Form for Admission Academic Year 2011/2012
Application for mailing

( Note: Please fill all details in block letters)
1.0 Personal Particulars
Surname *
First Name *
Middle Names *
(Note: The names and initial entered in this form must be exactly the same as those appearing on your A.C.S.E.E.- Form VI or other certificates to be used for admission. If there is no surname or middle in your certificate please do not write )
Sex *
Date of Birth *
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Attach Birth Certificate *
Place of Birth *
Citizenship *
Religion *
Marital Status *
Address *
City *
Country
E-mail Address *
Work Phone *
Cell Phone *
Profession *
Father's First Name *
Father's Surname *
Father's Profession *
Mother's First Name *
Mother's Surname *
Mother's Profession *
Do you have any kind of disabilty?
Disability Answer *
If yes, specify
Do you have any chronic or communicable disease that requires special medical attention? (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)
Medical Answer *
If yes, specify & attach information
Attach Medical Information

2.0 For Emergencies: Person to be contacted
Emergency Contact First Name *
Emergency Contact Last Name *
Relationship *
Address *
City *
Country *
Phone *
FAX
E-mail

3.0 Education Background & Employment Record: List all secondary schools attended.
School *
Location *
Date Started *
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Date Ended *
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cert. Index No. *
School 2 *
Location *
Date Started *
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Date Ended *
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cert. Index No. *
School 3 *
Location *
Date Started *
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Date Ended *
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cert. Index No. *
School 4 *
Location *
Date Started *
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Date Ended *
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cert. Index No. *

3.1 University/College Education
Have you attended this University/College or any other institutions of higher learning before?
Select *
If yes, please complete this information:
S/N
Institution Attended
Status

Qualification Attained
Date Qualification Attained
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
S/N
Institution Attended
Status

Qualification Attained
Date Qualification Attained
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
S/N
Institution Attended
Status

Qualification Attained
Date Qualification Attained
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Total number of years schooling
3.2 Please give details of your employment record below.
S/N
Name of Employer
Post Held
Dates of Employment
S/N
Name of Employer
Post Held
Dates of Employment
S/N
Name of Employer
Post Held
Dates of Employment

4.0 Programme sought in order of preference. (Select from the list attached)
First Choice of Programme Preference
Faculty *
Programme Code *
Full Name of Programme
Second Choice of Programme Preference
Faculty *
Programme Code *
Full Name of Programme
Third Choice of Programme Preference
Faculty *
Programme Code *
Full Name of Programme

5.0 Language Fluency
Language
Spoken

Written

Language
Spoken

Written

Language
Spoken

Written


6.0 Referees
Names and Addresses of two referees who know your ability as a student and can assess your competence in written and spoken English.
First Name *
Surname *
Address *
City *
Country *
First Name *
Surname *
Address *
City *
Country *

7.0 Sponsorship
The sponsor should indicate here that the candidate will receive support for years he or she will spend at the University of Bagamoyo.
First Name *
Surname *
Address *
City *
Country *
Phone *
Business or Activity
FAX
E-mail

Declaration
I declare that all information given in this form is correct. (Checking the box is required on the online application.)
Declare form is correct *
Date Application Completed *
Choose Date
Sun. Mon. Tue. Wed. Thu. Fri. Sat.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

8.0 Payments
Your non-refundable application fee of Tshs 20,000/= or US $ 25 should be paid to Legal and Human Rights Centre CRDB Account number 01J2019907100 Holand House Branch and submit the original pay-in slip together with the application forms. (No Cheques are accepted)

9.0 Attachments

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 history of your life in English (500-750 words or two fullscap) in your own handwriting, describing the important details of your life, your reasons for pursuing this courses of studies, and your plans for the future.
(d) Photocopies of your school certificates OR results slip
(e) Birth certificate
(f) Original pay slip of Tshs 20,000/= or $ 25When you have attached all required materials and have included certification of sponsorship (below) kindly send this to the office of the:

Admissions Office, University of Bagamoyo, P.O Box 75254 Dar es salaam, Tanzania.
Biography
A short history of your life in English (500-750 words or two fullscap) in your own handwriting, describing the important details of your life, your reasons for pursuing this courses of studies, and your plans for the future.
Your Story *

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