APPLICATION FORM

KILIMANJARO CHRISTIAN MEDICAL COLLEGE

ANAESTHETIC TRAINING SCHOOL

P.O.BOX 6441

MOSHI

Tel&Fax 53471

APPLICATION FORM FOR ANESTHETIC COURSE.

Duly complete the form in block letters or type and send it to:

The Principal,

Anaesthetic Training School,

P.O.Box 6441

Moshi

Tanzania.

1. I hereby make application for (circle one) AMO Anesthesia Nurse Anesthesia Course

2. Name: ___________________________________________________________

(Last) (First) (Middle)

3. Date of Birth: ______________________________________

(Month) (Day) (Year)

4. Nationality__________________________

5. Passport NO/ Identity No: ____________________________

6.Mailing Address: __________________________________________________________

(Number) (Street) (Hospital/Institution)

(City) (Country)

(Telephone/Fax) (email )

7. Basic Qualifications: (Circle one) Clinical Officer / AMO / Registered Nurse/ Nurse Grade A/ Nurse Grade B / Others (State)

8. _________________________________________

(APPLICANT’S SIGNATURE)

The following documents to be submitted in support of the application:

8.1. True copy of the Certificate of the basic qualification

8.2. Letter of Sponsor / and Referee.