1

P.O. BOX 1104

MBEYA
TANZANIA
TEL.: +255 25 2502682
FAX: +255 25 -2503721
Email: info@teku.ac.tz
Web: www.teku.ac.tz
TRAINING FOR BETTER LIFE

DIRECTORATE OF CONTINUING EDUCATION

APPLICATION FORM FOR ADMISSION INTO CERIFICATE PROGRAMMES
2014/2015 ACADEMIC YEAR.

To be filled in duplicate and sent to: The Deputy Vice Chancellor Academic Affairs
Teofilo Kisanji University, P.O. Box 1104, Mbeya, Tanzania.

(Please read carefully the Instructions to Applicants attached before filling in this
Application form)

NOTES:

i. This form should be typed or completed in BLOCK LETTERS, and returned to
Deputy Vice Chancellor Academic Affairs, Teofilo Kisanji University, P .O. Box 1104
MBEYA

ii. Attach copies of (a) Current appointment letter (where applicable). (b) Certified
professional and academic certificates and transcripts (c) 4 passport size photographs (d)
Original up pay in slip for application fee. (e) any relevant document to support your
application

iii. Attach the payment slip from the Bank for the non refundable application fee: Tshs. 30,000.00
(Thirty Thousand Tanzanian Shillings).

iv. *NO APPLICATION FORM SHALL BE PROCESSED WITHOUT AN APPLICATION FEE!

This fees should be deposited in any of the TEKU Account Numbers as follows:

S/No. Name of Bank Bank Account Number
1. NBC 016103001650
2. STANBIC 014001502028101
3. CRDB 01J1065895000
4. Commercial Bank of Africa (CBA) 0300786000
Come with pay in slip to the cashier for a University receipt.

SECTION A: PERSONAL PARTICULARS

1. Surname (Block/Capital Letters): .
First Name: . Middle Names:
(Note: The names entered in this form must be exactly the same as those appearing on your .C.S.E. Form IV or
other certificates to be used for admission.)

2. Sex: Male Female


Affix two
Stamp size
Photograph
2


3. Date of Birth (Attach a copy of birth certificate):..

4. Place of Birth: .. 5. Citizenship: ..

6. Religion: .. 7. Marital Status:.

8. Postal Mailing Address:

9. Telephone Number (s)

10. E-mail:

11. Do you have any kind of disability: Yes: No: if yes, specify:

(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)

NAME OF CERTIFICATE PROGRAMME APPLIED FOR . ...................................................................


SECTION B: ACADEMIC BACKGROUND AND EMPLOYMENT RECORD

Certificate of Secondary Education Examinations (C.S.E.E) /National Form IV/or Equivalent.
S/N Subject Grade Date Index No









Examination Authority . Division

Examination Centre or School:. Country:

Employment Record

Please give details of your employment record in the table below.
S/N Name of Employer Post Held Dates






SECTION C: SPONSORSHIP DETAIL
1. Indicate the type of sponsorship for your studies (please tick one)
Government of Tanzania Private Other (specify):

2. If you are not seeking sponsorship from the Government of Tanzania, give the full name, Address,
relationship and letter of commitment from each of your sponsors.

Full name Mailing Address Tel. Numbers (s) Relationship

Sponsor 1


Sponsor 2


Sponsor 3


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SECTION D: DEADLINE FOR RECEIVING OF APPLICATION FORMS.

The deadline for submission of dully filled application form is 30
th
June, 2014 - 16.00 pm.
Application forms received thereafter (submitted in person or otherwise) shall not be processed.

SECTION E: DECLARATION
I hereby declare that all information and data given in this form is correct and true to the best of my
knowledge and belief. I understand that any incorrect data and information given by me will make
liable to disqualification and dismissal as well as further legal action.

Also I declare that if I am admitted at Teofilo Kisanji University, I shall NOT take part in any strikes
or demonstrations which will disturb the operations of the University. I hereby accept that any
participation in the strikes or demonstrations shall lead me into dismissal from the University.

Signature of Applicant: Date:

Note: The information given in this form will be used for admission purposes only. Non-disclosure of
details or provision of false information to any of the sections in this form if discovered shall render your
registration with the Teofilo Kisanji University cancelled. Please also submit with these forms the attached
medical examination form.

FOR OFFICIAL USE ONLY
Application form has been received by the DOCE Admission Office
Name of Officer: ...

Signature .. Date:

Decision by DOCE Committee:











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TEOFILO KISANJI UNIVERSITY

P.O. Box 1104
MBEYA
Tel.: +255 25 2502682
Fax: +255 25 03721
Email: info@teku.ac.tz
Website: www.teku.ac.tz

PART II
MEDICAL EXAMINATION FORM

SECTION A
Past Medical History
Nervous System:
Any experience of loss of consciousness Yes/No-if yes, treatments

Any neurological deficiency Yes/No- if yes, treatments

Any experience of fits Yes/No if yes, treatments


Muscular-Skeletal System:
Any deformity, if yes, which part of the body
When acquired
Current status
Do use accessories or aids? If yes specify.

OTHER CHRONIC CONDITIONS:
Diabetes Mellitus- if yes, when detected?
What is the current status?
Herpes zoster, if yes when did it happen? ,
What part of the body was affected? If yes when was it
detected .
What is the current treatment?
Asthma, if yes, when was it detected and what is the current sort of treatment?

Allergies, if yes, what is the type of allergies
What is its cause of reaction?
Major surgeries, if yes, explain the types of surgeries. .
What was the date of surgery?
Do you experience any heart disease? If yes, what type and what are the current treatments?

Any dietary restrictions? If yes, state the restrictions.


I, declare that all he information provided here/in is true to the best of my knowledge

Signed date
SECTION B
To be completed by a Registered Medical Officer or Doctor

General Appearance:
Height weight


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BLOOD PRESSURE pulse rate . Lymph node Palpable
Skin appearance
Throat tonsillitis teeth dentition
EARS Right hearing Drum membrane . Left hearing Drum
membrane
Eyes, Rt va , squint. Lt. va squint
CORDIO RESPIRATORY SYSTEM - Chest X-ray film and reports are needed
Lung fields Breast lampus ,
heart size heart sounds
ABDOMINAL EXAMINATION abdominal USS report is needed if mass detected film is needed
Contour size- sunken/normal/distended, skin scar , umbirilicus
Hernia
MUSCULO SKELETAL SYSTEM
Any deformation? Yes/No-if yes which part of the body? Type if deformation

BIOCHEMICAL:
Fasting blood sugar
Serum creatinine
Serum Alanine T.
Serum asoantate T
Blood urea
Uric acid
IMMUNOLOGY
VDRL reaction if +VE

treatment
Widal Test if +VE treatment
Contact with Human immunodeficiency virus conversation (optional)

HAEMATOLOGY-CULTURE COUNTER
Haemoglobin , white cells count
PARASITOLOGY
Stool routine examination , treatment
Urinalysis and microscopy , treatment
Blood smear and sediment microscopy , treatment
,
Is there any other observation whether irritable aggressive

Declaration

I, Dr. , of have examined
the above named candidate
And conclude that the candidate is/is not it to pursue her/his studies.

Signed date

*Delete which does not apply










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TEOFILO KISANJI UNIVERSITY






Training for Better Life

DIRECTORATE OF CONTINUING EDUCATION (DOCE)

NON DEGREE PROGRAMMES

FOR 2013/2014 ACADEMIC YEAR






































S/No. PROGRAMME TITLE
1.
Certificate in Education
2.
Certificate in Law
3.
Certificate in Human Resource Management
4.
Certificate in Business Administration
5.
Certificate in Community Development and Social Work
6.
Certificate in Entrepreneurship
7.
Certificate in Information Technology
8.
Certificate in Accounting and Finance
9.
Certificate in Procurement, Logistics and Management
10.
Certificate in Journalism and Mass communication
11.
Certificate in library and Information Science


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A: CERTIFICATE
TANZANIA STUDENTS (IN TANZANIA SHILLINGS)
DIRECT COSTS TO THE UNIVESITY
(Payable to the University)

Application fee 30,000.00
Registration fee 30,000.00
SUBTOTAL 60,000.00
Tuition fee 600,000.00
Examination fee 40,000.00
Caution Money 30,000.00
Identity Card 10,000.00
Student union 15,000.00
Field Training/Teaching Practice 40,000.00
TEKU Development Fund 20,000.00
SUBTOTAL 755,000.00
TOTAL 815,000.00

INDERECT COSTS ( Incurred by the
Student/Sponsor during studies)

Accommodation and meals (240 days @
Tshs 25,500, estimated) per annum
1,590,000.00
Health Insurance (estimate) 100,000.00
Books and Stationery (estimated) 300,000.00
Internet Services (estimate) 50,000.00
Graduation Ceremony Purchase of graduation Gown
(optional)
40,000.00
Independent Research Project (estimated) 500,000.00
Teaching Practice/field Attachment (estimated) 420,000.00
SUBTOTAL 3,000,000.00
GRAND TOTAL 3,815,000.00

All payments are to be made through deposits in: Teofilo Kisanji University Account as
follow:
S/NO NAME OF BANK BANK ACCOUNT NUMBER
1 NBC 016103001650
2 STANBIC 014001502028101
3 CRDB 01J1065895000
4 CBA 0300786000

NB: All fees can be revised from time to time as per Council approval.
Come with pay in slip to the cashier for a University receipt. Pay-in slips must be presented to the cashier for official/university
receipts within five (5) days. Delay of submission of the pay-in slips to the cashier shall cost you Tshs. 10,000. Note: The tuition fees
shall be paid in four instalments. Please abide to the TEKU Financial Rules and Regulations!