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.