CENTRE FOR FOREIGN RELATIONS
DAR ES SALAAM
APPLICATION FOR ADMISSION FOR ACADEMIC YEAR 2014/2015
1.
PROPOSED STUDY:
Post graduate Diploma in Management of Foreign Relations: Evening
Post graduate Diploma in Economic Diplomacy: Evening
Diploma in International Relations and Diplomacy: Regular/Evening
Certificate in International Relations and Diplomacy: Regular/Evening
2.
PERSONAL DETAILS:
SURNAME ……………………. FIRST NAME ……………………... MIDDLE NAME …………………….
DATE OF BIRTH ………………………………………. . NATIONALITY …………………………………….
MARRITAL STATUS
Married
Single
Widower
NAME OF NEXT OF KIN ……………………………………. RELATIONSHIP ……………………………….
OCCUPATION ……………………………………………………….
3.
ADDRESSES:
PERMANENT ADDRESS ……………………………..………………………………………………………….
TELEPHONE …………………………… E-mail ………………………………………
PRESENT ADDRESS ………………………………………………………………………………………………
TELEPHONE ………………………………………………………. E-mail ………………………………………
ADDRESS OF NEXT OF KIN ……………………………………………………………………………………...
TELEPHONE ………………………………………………………. E-mail ………………………………………
4.
EDUCATION QUALIFICATIONS:
O-LEVEL (WRITE ONLY SUBJECTS WITH CREDITS i.e. D and above)
SUBJECT
MARKS
DATE
INDEX NO.
SCHOOL/CENTRE
POINTS
DIVISION
A-LEVEL (WRITE ONLY SUBJECTS WITH Principals and Subsidiary)
SUBJECT
MARKS
DATE
INDEX NO.
POINTS
DIVISION
SCHOOL/CENTRE
OTHER QUALIFICATIONS: (Degree, Advanced Diploma, Diploma, Certificate)
PROGRAMME
5.
CLASSIFICATION
DATE
COLLEGE/UNIVERSITY
LANGUAGE PROFICIENCY:
Indicate proficiently level estimate (e.g. excellent, good, fair, poor)
LANGUAGE
READING
WRITING
Kiswahili
English
Spanish
French
Arabic
6.
EMPLOYMENT EXPERIENCE:
POSITION HELD
7.
SPEAKING
EMPLOYER AND ADDRESS
PERIOD OF EMPLOYMENT
EXTRA CURRICULAR ACTIVITIES:
(i) …………………………………. (ii) ………………………………… (iii) …………………………………
8.
DISABILITY/SPECIAL NEEDS:
The Centre realizes that some members of the community have special needs. The information you provide will
not affect judgments concerning your academic suitability and will be treated confidentially.
Do you have a disability
YES
NO
If yes, please provide further details in the space below:………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
9.
REFERENCES:
Please give two names of your Referees
1.
Name (including title) ……………………………………………………………………………………..
Address ……………………………………………………………………………………………………
2.
Name (including title) ……………………………………………………………………………………..
Address ……………………………………………………………………………………………………
10.
DECLARATION
In the event of, and in consideration of the Centre accepting me as a student, I hereby undertake to pay, as and
when due all Centre fees. I understand that the payment of tuition fees be made in advance or at registration. I
certify that I enjoy good health and that I am not now suffering from any disease likely to interfere either with
studies or with the health of other students.
I hereby certify that all the above information is correct and complete, and I desire to apply for admission as a
student of the Centre and declare that, if admitted, I undertake to conform to all the Rules and Regulations of the
Centre for Foreign Relations.
Signature of the applicant…………………………………..
Date……………………………………………..…
APPLICATION CHECK LIST
This application form should be returned accompanied with:
2 Letters of reference
Certified copy of Certificates, Diplomas or University degrees
4 passport size recent photographs
Receipt of 30,000/= (for application and entrance examination)
Letter of confirmation for Sponsorship
Medical Report Form
APPLICATION SUBMISSION
This form should be completed and returned on or before Saturday 12th July, 2014 to:
Deputy Director Academic, Research and Consultancy
Centre for Foreign Relations
P.O. Box 2824
DAR ES SALAAM
A/C No. 20101100061 NMB Bank
CENTRE FOR FOREIGN RELATIONS
DAR ES SALAAM
REFERENCE TO SUPPORT APPLICATION
FOR ADMISSION
SECTION 1: To be completed by applicant BEFORE submitting to referee.
Provide Information as you did on application for Admission.
1.
2.
Name of Applicant: …………………………………………………………………………………
Programme applied for: ……………………………………………………………………………….
SECTION 2: To be completed by a referee
The above-named is applying for admission at this Centre, and has named you as an academic referee. The
Centre would be grateful if you could complete this form and return it in the enclosed envelope, to the applicant
as soon as possible.
1.
2.
3.
4.
5.
6.
Name of referee: …………………………………………………………..........................................
Designation: …………………………………………………………………………………………..
Address: ………………………………………………………………………………………………
Telephone: ……………………………………e-mail………………………………………………..
How long and in what capacity have you known the applicant ……………………………………..
If the applicant’s first language is not English please comment on the level of competence.
excellent
good
fair
poor
Written
Listening and comprehension
Spoken
Reading
7.
In comparison with others at a similar level, this applicant may be considered:
Outstanding
8.
Above Average
Average
Below Average
In your opinion, to what extent does the applicant posses intellectual, practical and personal abilities that
are required to cope with the Centre’s grueling programmes?
Signature: ………………………………………..
Date: ………………………...
CENTRE FOR FOREIGN RELATIONS
DAR ES SALAAM
MEDICAL REPORT
FULL NAME: …………………………………………………………………………………………………………………
SEX: …………………………………………….. AGE: ……………………………………………………………………
HEIGHT: ……………………………………….. WEIGHT: ……………………………………………………………….
Medical Examiner is requested to provide categorical answers to the following:YES
NO
1.
Any eye trouble
9.
Diabetes
YES
2.
Nose or throat trouble
10.
Heart Disease
3.
Ear trouble or deafness
11.
Fits or Seizures
4.
Haemorhoids
12.
Cancer
5.
Kidney or bladder trouble
13.
Operations
6.
Skin Disease
14.
Accidents
7.
Venereal Diseases
8.
Stomach trouble
17.
Eye:-
Conjunctive
15.
16.
NO
Physical defect
Lung or chronic cough
…………………………………………….
Pupils ……………………………………….
Sight: Without Glasses
Right ………………………………………. Left ……………………………...
With Glasses
Right ………………………………………. Left ……………………………...
20.
21.
Respiratory System …………………………………………………………………………………………………...
Cardio Vascular …………………………………….. Pulse ………………...............................................................
Blood Pressure: Systolic ……………………………… Diastolic …………………………………………………...
Any clinical evidence of hyperacidity or gastric ulcer …………………………………….........................................
BLOOD
VDRL ………………………………… Haemoglobin …………………………. Leucocytes …………………….
Neutrophils ……………………………………….. Lymophocytes ………………………………………………..
Resophil…………………………………………… Eosmophiles …………………………………………………..
Monocytes …………………………………………. Blood Group ……………………………………………….
22.
Eythrocyte Sedimentation Rate
23.
CHEST X-RAY
The heart size …………………………………………………………………………………………………………
The lung field …………………………………………………………………………………………………………
Thoracic cafe ………………………………………………………………………………………………………….
Conclusions …………………………………………………………………………...................................................
18.
19.
ELABORATE ON POSITIVE FINDINGS
I certify that MR/MRS/MISS ………………………………………………………………………………….........................
Is FIT/UNFIT to undertake studies at the Centre for Foreign Relations, Dar es Salaam. (cross whichever is appropriate in).
DATE: …………………………………………………………………………………………………………………………
PLACE: ………………………………………………………………………………………………………………………...
MEDICAL EXAMINER’S SIGNATURE: …………………………………………………………………………………….
QUALIFICATIONS: …………………………………………………………………………………………………………..
ADDRESS: …………………………………………………………………………………………….....................................
TELEPHONE: ………………………………………………………………………………………………………………....