DECCA COLLEGE OF HEALTH AND ALLIED SCIENCES (DECOHAS) P. O. Box 372, CCT, Dodoma – Tanzania Tel/Fax: +255 26 2322357, Mob: +255 767 832211/+255 655 407282 Website: www.decohas.ac.tz, E-mail: dpfa@decohas.ac.tz, info@decohas.ac.tz Attach three colored passport PHARMACY DISPENSING NTA LEVEL 4 size photos STUDENT APPLICATION FORM (Carefully read the ‘Instructions to Applicants’ before filling in this application form. This form can be typed or handwritten) Academic Year for which admission is sought (e.g. 2015/2016): ………………………………………………………. BASIC CERTIFICATE IN PHARMACY DISPENSING ONE YEAR COURSE In the table below, enter the Programme you would like to study. Details of the Certificate Programmes are given in the “Instructions to Applicants”. Choice of programme NTA LEVEL 4 Section 1: Department Programme Full Name of Programme Applicant Details (Please complete in BLOCK letters or typed) Last Name First Name Middle name Date of Birth Gender Nationality Male Female Marital Status Do you consider yourself to have a disability? Yes No Single Married No. of Children Do you have a criminal conviction? Yes Permanent Home Address Address for Correspondence (If different from Home Address) City City Country Country Telephone Telephone Email No Please write your e-mail address clearly Page 1 of 4 Education Details (your qualifications must demonstrate eligibility for the course, complete in BLOCK letters or type) Section 2: List all academic qualifications that you have achieved “O”, “A” level grade or equivalent. Copies of all relevant final transcripts must be attached with this application. Qualification From To School / College/ University name Grade / % Marks List any results you are awaiting and including anticipated grades. Qualification/course/examinati on Section 3: Exam date Employment Details: School /College/University name Expected grade (Important if you are applying as a mature age entry). Please give details of positions held over the past 5 years, if you are applying as a mature – age or for admission as a post graduate, provide detailed job descriptions on separate page and attach documentary evidence, e.g. reference letters from employers. Employer name Section 4: Address Accommodation Position held From (tick √ if you need accommodation) To YES NO N.B: All residents are required to sign an accommodation tenant agreement form /contract before allocated to the room. In a room you will find a bed, mattress and keys Section 5: Finance Indicate how you intend to finance your studies and your living expenses in Dodoma. How will you finance your studies at DECOHAS? Family Employer Parents/Guardians Job Title Telephone No. E-mail Loan Savings Other Page 2 of 4 Sponsor Declaration: I have agreed to finance the above named applicant in his/her studies at DECOHAS and agreed to release funds for tuition fees and living expenses as and when required. Signed: __________________________ Name __________________________ Date: ___________ Section 6: References (Please compete in BLOCK letters or type). Please provide the names of two referees; at least one should be an academic referee who has knowledge of your academic ability. Referee name Address Telephone E-mail Section 7: Fee Structure All payments shall be paid to DECOHAS Bank accounts at CRDB Bank Plc Tuition fee: DECOHAS Tuition, Account No. 0150222135400 Other payments: DECOHAS Miscellaneous, Account No. 0150222135500 Bring bank pay - in slips to the college. The fees are payable in full or in two installments at the beginning of each academic year / semester. Upon Return of this form, bring the pay-in slip of the application fee of Tshs 30,000/= Paid to DECOHAS Miscellaneous, Account No. 0150222135500 Note: All payments other than Tuition fees should be paid to the DECOHAS Miscellaneous Account number stated above Application should be done directly to the College Principal, DECCA College of Health and Allied Sciences (DECOHAS) P. O. Box 372, Dodoma Tel/Fax: +255 26 2322357, Mob: 0767 182 106, 0717 514 324, 0767 832, 211, 0786 407 282 Website: www.decohas.ac.tz E-mail: decohas@gmail.com Page 3 of 4 A: Tuition fee Per annum Tshs,800,000/= B: Other Charges/Payments DESCRIPTION Registration fee per semester Pharmacy Council Exams Fees NACTE Quality Assurance Fee Accommodation per annum Medical fee per annum Practicum Guide & Field attachment fee Examination fee per semester Caution money (paid once) Identity Card (paid once) Students Union (DECOHASSO) Fee per annum Meals Total cost to College DAY (TSHS) 10,000 150,000 15,000 0 60,000 160,000 50,000 100,000 10,000 HOSTEL (TSHS) 10,000 150,000 15,000 400,000 60,000 160,000 50,000 100,000 10,000 10,000 10,000 0 565,000. 1,500,000 2,465,000 Page 4 of 4