Application For Admission For Academic Year 2019/2020 1. Proposed Study

CENTRE FOR FOREIGN RELATIONS
DAR ES SALAAM
APPLICATION FOR ADMISSION FOR ACADEMIC YEAR 2019/2020
1. PROPOSED STUDY:
Postgraduate Diploma in the Management of Foreign Relations: Evening
Postgraduate Diploma in Economic Diplomacy: Evening
Postgraduate Diploma in Peace and Conflict Management:/Evening
Higher Diploma/Bachelor Degree in International Relations and Diplomacy: Regular/Evening
Technician Certificate/Ordinary Diploma in International Relations and Diplomacy: Regular/Evening
Basic Technician 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. POINTS DIVISION
SEC SCHOOL/CENTRE
PRIMARY SCHOOL(For Cert/Dip/Bach)
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 CLASSIFICATION DATE COLLEGE/UNIVERSITY
5. LANGUAGE PROFICIENCY:
Indicate proficiently level estimate (e.g. excellent, good, fair, poor)

LANGUAGE READING WRITING SPEAKING
Kiswahili
English
Spanish
French
Arabic
6. EXTRA CURRICULAR ACTIVITIES:
(i) …………………………………. (ii) ………………………………… (iii) …………………………………
7. 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:-

………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
8. REFERENCES:
Please give two names of your Referees
1. Name (including title) ……………………………………………………………………………………..
Address ……………………………………………………………………………………………………
2. Name (including title) ……………………………………………………………………………………..
Address ……………………………………………………………………………………………………
9. 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:

Birth Certificate
Certified copy of Certificates, Diplomas or University degrees
4 passport size recent photographs
Receipt of (30,000/= for PGD) and (10,000/= for CERT/DIP and BACH)
Letter of confirmation for Sponsorship
Medical Report Form
APPLICATION SUBMISSION
This form should be completed and returned on or before Sunday, 15th August, 2019 to:
Deputy Director Academic, Research and Consultancy

Centre for Foreign Relations
P.O. Box 2824
DAR ES SALAAM
A/C No. 20101100203 NMB Bank

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. Name of Applicant: …………………………………………………………………………………
2. 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. Name of referee: …………………………………………………………..........................................
2. Designation: …………………………………………………………………………………………..
3. Address: ………………………………………………………………………………………………
4. Telephone: ……………………………………e-mail………………………………………………..
5. How long and in what capacity have you known the applicant ……………………………………..
6. 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 Above Average Average Below Average
8. 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: ………………………...

DAR ES SALAAM
MEDICAL REPORT
FULL NAME: …………………………………………………………………………………………………………………

SEX: …………………………………………….. AGE: ……………………………………………………………………
HEIGHT: ……………………………………….. WEIGHT: ……………………………………………………………….
Medical Examiner is requested to provide categorical answers to the following:-

YES NO YES NO
1. Any eye trouble 9. Diabetes
2. Haemorhoids 12. Cancer
3. Kidney or bladder trouble 13. Operations
4. Skin Disease 14. Accidents
5. Venereal Diseases 15. Physical defect
6. Stomach trouble 16. Lung or chronic cough
17. Eye:- Conjunctive ……………………………………………. Pupils ……………………………………….
Sight: Without Glasses Right ………………………………………. Left ……………………………...
With Glasses Right ………………………………………. Left ……………………………...
18. Respiratory System …………………………………………………………………………………………………...

19. Cardio Vascular …………………………………….. Pulse ………………...............................................................
Blood Pressure: Systolic ……………………………… Diastolic …………………………………………………...
20. Any clinical evidence of hyperacidity or gastric ulcer …………………………………….........................................
21. 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 …………………………………………………………………………...................................................
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: ………………………………………………………………………

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CENTRE FOR FOREIGN RELATIONS

APPLICATION FOR ADMISSION FOR ACADEMIC YEAR 2019/2020

Postgraduate Diploma in the Management of Foreign Relations: Evening

Postgraduate Diploma in Economic Diplomacy: Evening

Postgraduate Diploma in Peace and Conflict Management:/Evening

Higher Diploma/Bachelor Degree in International Relations and Diplomacy: Regular/Evening

Technician Certificate/Ordinary Diploma in International Relations and Diplomacy: Regular/Evening

Basic Technician Certificate in International Relations and Diplomacy: Regular/Evening

SURNAME ……………………. FIRST NAME ……………………... MIDDLE NAME …………………….

DATE OF BIRTH ………………………………………. . NATIONALITY …………………………………….

MARRITAL STATUS Married Single Widower

NAME OF NEXT OF KIN ……………………………………. RELATIONSHIP ……………………………….

PERMANENT ADDRESS ……………………………..………………………………………………………….

TELEPHONE …………………………… E-mail ………………………………………

PRESENT ADDRESS ………………………………………………………………………………………………

TELEPHONE ………………………………………………………. E-mail ………………………………………

O-LEVEL (WRITE ONLY SUBJECTS WITH CREDITS i.e. D and above)

OTHER QUALIFICATIONS: (Degree, Advanced Diploma, Diploma, Certificate)

PROGRAMME CLASSIFICATION DATE COLLEGE/UNIVERSITY

Indicate proficiently level estimate (e.g. excellent, good, fair, poor)

6. EXTRA CURRICULAR ACTIVITIES:

(i) …………………………………. (ii) ………………………………… (iii) …………………………………

Do you have a disability YES NO

If yes, please provide further details in the space below:-

Signature of the applicant…………………………………..

APPLICATION CHECK LIST

This application form should be returned accompanied with:

Medical Report Form

Deputy Director Academic, Research and Consultancy

A/C No. 20101100203 NMB Bank

REFERENCE TO SUPPORT APPLICATION

SECTION 1: To be completed by applicant BEFORE submitting to referee.

SECTION 2: To be completed by a referee

excellent good fair poor

7. In comparison with others at a similar level, this applicant may be considered:

Signature: ……………………………………….. Date: ………………………...

FULL NAME: …………………………………………………………………………………………………………………

Medical Examiner is requested to provide categorical answers to the following:-

18. Respiratory System …………………………………………………………………………………………………...

22. Eythrocyte Sedimentation Rate

23. CHEST X-RAY

ELABORATE ON POSITIVE FINDINGS

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