PASSPORT

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APPLICATION FORM
Please complete this form in BLOCK LETTERS
PERSONAL DATA
Surname Middle Name First
Name
Date of Birth: Gender: (Tick) Male Female
(Date) (Month) (Year)
Nationality: Country: I.D/Passport No:
Marital Status: Single Married Other(Specify)
Religious Affiliation (Christian, Muslim, Hindu, Specify Other)

CONTACT DETAILS
Postal Address: Postal code: Town: Country:
Mobile: Home/Office Tel Number:
eMail:

PARENT’S/GUARDIANS/NEXTOF KIN’S INFORMATION

Name: Relationship:
Postal Address: Postal code: Town: Country:
Mobile: Home/Office Tel Number:
eMail:

FINANCIAL DATA
Who will sponsor your education at NMTC? (Tick)
Self Parent Guardian Sponsor
SELF/PARENT/GUARDIAN/SPONSOR’S INFORMATION
Name: Relationship:
Postal Address: Postal code: Town: Country:
Mobile: Home/Office Tel Number:
eMail:
Dear Prospective Student,

Greetings from Nyahururu Medical Training College (NMTC), we pray the best for you as you
begin your academic journey with us.
NMTC, is fully accredited or recognized as full-fledged tertiary Health Training Institution by
the following regulatory and accreditation authorities:
a. Technical and Vocational Education and Training Authority (TVETA)
b. Nursing Council of Kenya (NCK)
c. Clinical Officers Council of Kenya (COC)
d. Association of Medical Records Officers of Kenya ( AMRO-K)
e. Kenya Nutritionists and Dieticians Institute (KNDI)
Our intakes are in January, March, June and September. Applications are received and
processed throughout the year.
Bring/Scan/Post the following: -
 Completed application form
 Non-Refundable Application fee of Kshs. 1500 (East African countries) or US$20 for
international applicants. To be deposited Via NMTC MPESA PAYBIL Number /
Schools Account and attach a copy of Deposit slip.
 3 Passport size photographs (write your full names at the back)
 Copies of official Academic Documents – Result slips, Transcripts, Certificates – this
includes proof you have done English for those from Non-English speaking countries.
 Copy of your National ID/Passport
 Birth certificate

MPESA PAYBIL: 4027937

ACCOUNT: STUDENT NAME

OR

Account Name: Nyahururu Medical Training College

Bank: ABSA Bank, Nyahururu Branch
Account Number: 2033563836
Swift code: BARCKENX (For international students)

NB: Bring along your original certificates and results/transcripts on the day of Admission
The Application Form should be filled and either submitted by person to the admissions office in
the College or scanned and emailed to [email protected] or by Post addressed
to The Principal NMTC, P.O. BOX 1804-20300 Nyahururu, KENYA

Should you still have questions please do not hesitate to contact the Principal NMTC through
any of the contacts given above.

Thank you for choosing NMTC.

Kind regards

Principal NMTC
 COURSE DETAILS

Course tittle:

MODE OF STUDY(Tick)
Regular Evening Weekend eLearning

INTAKE(Tick)

January March June September YEAR:

QUALIFICATIONS
Academic Level Institution Year attended Qualification
(Eg. High Sch,Cert,Dip,Degree)

Have you been or discontinued from another institution before? Yes/No

If YES give the name of the institution and reason

WORK EXPERIENCE(Optional)
Organization Date Position

ADDATIONAL INFORMATION
1. Do you suffer from any medical condition that requires you to see a Doctor often or take
frequent medication? Yes/No
If yes specify
2. Do you suffer from any food allergies? Yes/No
If yes specify
3. Do you suffer from any disability? Yes/No
If YES, specify

If yes to any of these questions what support would you require while at NMTC?

Note: additional information is required for planning purpose not for selection criteria
 REFEREE’S INFORMATION
Name: Position:
Address: Town: Postal Code:
Telephone Number: Email:

How did you know about NMTC?

I hereby apply for admission at Nyahururu Medical Training College(NMTC) and I confirm
that the information provided above is correct to the best of my knowledge. I understand that any
offer of admission may be withdrawn if I cannot provide documentary evidence of any
statements on this form.

Signature Date: _

FOR OFFICIAL USE ONLY

A ) Required Documents
Result slip/Transcripts
High-school/Degree Certificate
School leaving certificate
Application fee
Medical Certificate( from a certified Medical Practitioner)
B ) Recommendation by admission panel
Approved for admission in
Not approved: Reason
Pending approval after receiving the following documents/information
1.
2.
Officer Name:
Signature: Date:

C ) Action by the Principal

Admitted Not admitted
Other action:

Signature: Date: