Application for Admission — Palliative Care Training

1.0 Personal Particulars

1.1 Full Name *

1.2 Sex *

Male

Female

1.3 Date of Birth *

1.4 Place of Birth

1.5 Place of Residence

1.6 Nationality * Tanzanian nationals pay in TZS; others pay in USD.

1.7 Religion

1.8 Marital Status

1.9 Postal Address

2.0 Phone Number *

2.1 Email Address *

3.0 Education

Select all qualifications that apply.

Diploma in Nursing/Midwifery

Diploma in Clinical Medicine

Degree of Doctor of Medicine (MD)

Degree of Pharmacy

Others (please specify)

4.0 Occupation

Select your current occupation.

5.0 Course Fee Payment

Tanzanian Participants

TZS 800,000/=

Eight Hundred Thousand Shillings

International Participants

USD $350.00

United States Dollars

Bank Transfer Details

Bank Name

CRDB Bank PLC

Account Holder

College of Agriculture and Food Technology

Account Number

0150690896700

Who is sponsoring your course fee? *

Self-sponsored

Relative

Employer

Other

Sponsorship Details

Proof of Payment (optional — you may upload later) Accepted: PDF, JPG, PNG. Max 5 MB.

6.0 Personal Statement

Write half a page describing why you want to undertake the training in Palliative Care.

7.0 Prospect Development

Briefly describe how you see your prospect development in Palliative Care (immediate and long term).

8.0 Knowledge Sharing Plan

Briefly describe how you plan to share your knowledge and skills in Palliative Care.

9.0 Declaration

I hereby declare that the above information provided is true and correct to the best of my knowledge.

I confirm that I have read and agree with the above declaration.