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MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES

REGISTRATION FORMS – DIPLOMA PROGRAMMES
2018/2019 ACADEMIC YEAR

NOTE: i) This form must be completed by every first year student at the time of registration
ii) When completed and certified by the Deputy Vice Chancellor – Academic, Research
and Consultancy; one copy will be retained by the Admission office and the second
copy will be kept by the relevant School.

Registration No:

(Diploma for which registration is sought must be the same as that appearing in your student identity
card)

School:

Diploma Programme

1. Surname (Block Capitals)

2. First Name (Block Capitals)

3. Middle Names (Block Capitals)

(The names entered on this form must be the same as those on your letter of admission. These
are the names apearing on your “O-Levels certificate or equivalent documents submitted as
entry qualifications)

4. Date of Birth 5. Age of

Entry (Yrs)
Day Month Year

6. Sex 7. Nationality
MALE FEMALE

8. Marital Status

(Tick one) Married Single Divorced Widowed

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9. Permanemt Home Address
(Postal)_____________________________________________________________________
___________________________________________________________________________
Tel. No. _____________________Email _______________________________________
Bank Name_______________________AccountNo._______________________________

10. Religion (Christian, Islam, Hindu

etc)__________________________________________________

11. Hall of Residence____________________________________________________________

If non-resident (give) Postal Address___________________________________________

b) ResidentialAddress_________________________________________________________

12. Do you have any physical or communication disabilities? (Tick whichever is applicable)
i) Vision/mobility/speech/hearing/others _______________
ii) Type and Magnitude ____________________________
iii) Duration of the disability ____________________________
iv) Type of supportive gearused/required___________________
v) Have you been receiving any humanitarian support for your disabilities? Yes/No If Yes,
give the name and address of a person or organisation which supports you.
_____________________________________________________________________
_____________________________________________________________________
NB: This information is to prepare the University to receive you and it will not
mitigate against your admission.

13. Secondary Schools, Collegeattended and dates:

___________________________________________________________________________
___________________________________________________________________________
_______________________________________________________________
14. Manner of entry to this University (Tick whichever is aplicable)
i) With O-Level qualifications _______________
ii) Equivalent qualifications (eg. Certificate) ______________________

15. Do you hold originals of your (Tick whichever applicable)

i) CSEE/Form IV or equivalent documents? __________________
ii) ACSEE/Form VI or equivalent documents? __________________
16. a) Certificate of Secondary Education/Form IV/Equivalent

Subject Grade Date Certified by Reg. Officer

Examination Authority_________________________________Index No.________________

Examination Centre:
(School)____________________________Country__________________________

Division__________________________

b) Advanced Certificate of Secondary Education/Form VI or equivalent results:

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Subject Principal or Grade Date Certified by Reg. Officer
Subsidiary
Level Credit

Examination Authority_________________________________Index
No.________________________
Examination Centre
(School)____________________________Country__________________________

Division__________________________

17. Any other University entrance qualifications (eg. Certificate/Diploma/FTC etc)

Yes/No_______________________
If YES type of
qualification______________________________________________________________
Year of Graduation________________Class or final GPA__________________Index
No____________

18. a) If prior to your admission you were a working person, have you been officially released by
your employer? Yes/No________________

b) If yes, provide documentary

evidence___________________________________________________

19. a) What are your extra curricula activities?

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
__________________________________________________________________

b) Indicate organization (s) of which you are a member citing the number of your member-
ship card as well as posts held:

Name of Organisation Membership Card No. Post held in the

organisation

20. What is your occupation goal?

1st Choice____________________2nd Choice_______________________3rd
Choice______________

21. a) Name of the father/guardian (state relaltionship)___________________________________

b) Postal
Address_____________________________________________________________________
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___________________________________________________________________________
________________________________________________________
Telephone No.___________________________Email Address____________________
c)Occupation of this person_____________________________________________________

22. Name of next of kin (state relationship)___________________________________________

Postal
Address____________________________________________________________________
___________________________________________________________________________
Telephone No.__________________________Email Address_________________________
c)Occupation of this person_____________________________________________________

23. Name and Address of your sponsor_______________________________________________

Postal Address______________________________________________________________
___________________________________________________________________________
Telephone No.__________________________Email Address________________________

24. Confirmation of fees payment (If privately sponsored)

Receipt Number_______________________________Amount paid_____________________

Bursar__________________________________________Date________________________

Signature and Stamp

25. Declaration by the Student

(Incorrect information may lead to serious consequences as stated in the Admission Letter, i.e
cases of impersonation of documents whenever discovered, either at registration or
afterwards, will lead to automatic cancellation of admission).

a) I declare that to the best of my knowldge that all the information given in this form is
correct.
b) i) I DO HEREBY UNDERTAKE to study diligently and seek the truth of knowledge.
ii) I DO HEREBY UNDERTAKE to obey all lawful authorities in the University, to
observe the regulations of the University, TO EXERCISE DISCIPLINE and also to
promote the good name of the University.

Signature of student__________________________________Date_____________________

Admission Officer
I declare that on the basis of the documentary evidence available in respect of statements made
in paragrapph 14 to 15 above and in all other aspects, the candidate is hereby registered.

__________________________________ ____________________
Full name Signature

For: Director of Undergraduate Studies

________________________________
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Date

_________________________________ _________________________________
Full Name and Signature For Deputy Vice Chancellor
Academic, Research and Consultancy

______________________________

Date

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