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Application Form - Student Indexing

This document contains an application form for student indexing from the Health Professions Council of Zambia. The form requests personal information from applicants such as name, date of birth, nationality, contact details, education history and mandatory subjects passed. Applicants must provide copies of acceptance letters, proof of payment, Grade 12 certificate, photo ID, and passport photo. Payments can be made at two specified banks, and a receipt will be issued upon proof of payment. The form also outlines an review and approval process involving registration officers, assistant registrars and the registrar.

Uploaded by

Beenzu Briella Siamalube
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
793 views

Application Form - Student Indexing

This document contains an application form for student indexing from the Health Professions Council of Zambia. The form requests personal information from applicants such as name, date of birth, nationality, contact details, education history and mandatory subjects passed. Applicants must provide copies of acceptance letters, proof of payment, Grade 12 certificate, photo ID, and passport photo. Payments can be made at two specified banks, and a receipt will be issued upon proof of payment. The form also outlines an review and approval process involving registration officers, assistant registrars and the registrar.

Uploaded by

Beenzu Briella Siamalube
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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11 Appendixes

11.1 Appendix 1: Application form for Student Indexing


Form 1 INDEX NO.................

Please affix firmly


a recent Passport -
size Color
HEALTH PROFESSIONS COUNCIL OF ZAMBIA photograph of
No. 7 Chaholi Road, Off Addis Ababa Drive, Rhodespark yourself here
P.O BOX 32554 Lusaka 10101, Zambia. Tel:+260 211 236241 Fax: +260 211
239317
Email: [email protected] Website:www.hpcz.org.zm

APPLICATION FOR INDEXING OF STUDENTS

Surname.…………………………..…………….Fore name(s)……………………………………………………
Gender……………… Date of birth……………………………….Nationality……………………………………
NRC No. …………………..……….Passport No. (ONLY if not in possession of NRC)…………………………
Physical address…………………………………………………………………………………………………….
Tel/Mobile………………………………………………………………………………………………………….
Email address.………………………………………………………………………………………………………
Name and Phone No. of Next of Kin..……………………………………………………………………………..
Training Institution..…………………………………………………………………………..……………………
Programme Pursued:……………………………………………………………………………………………….
Intake (month/year of enrolment)……..……………………………………………………………………………
Previous Training Institution attended (If applicable)……………………………………………………………..
Secondary School Attended …………………………………………………………….…………………………
Number of ‘O’ Level subjects attempted ......................................................................
Mandatory subjects Passed (indicate grade on applicable subjects)
English…………….. Mathematics……………… Biology/Agricultural Science …………….
Physics…………….. Chemistry…………………. Science …………………………………….
Any other subject (Name)…………………………...

I…………………………………………………………………………..do solemnly declare as follows:


a) That the information provided in this form is correct and true
b) That the attatched documents are genuine and that I make this solemn declaration conscientiously
believing the same to be true to the best of my knowledge and belief.

………………………………………
Signature of the Applicant

Declared at ………............. this ……………….. day of …………….. 20 …………….before

me……………………………………………………………………………………………………
Commissioner of Oaths/Notary Public

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MANDATORY ATTACHMENTS:

a) Copy of acceptance letter/ proof of enrollment from the training Institution


b) Proof of payment of fees
c) Certified copy of the Grade 12 certificate or its equivalent (Equivalents must be equated to the Zambian
system)
d) A photocopy of the National Registration Card/ valid immigration and passport documents for non-Zambians
e) One passport size photograph (Observe formal dress code not casual attire) with white background

NOTE: All payments should be made at Zambia National Commercial Bank using a Bill Muster form or
Stanbic Bank, Arcades Branch account number 9130002152316, Sort code 040010. A receipt shall be issued
upon presentation of proof of payment

For Official use:

Amount Paid………………………..Receipt No. ………………… …Signature …………Date stamp …………………


(Accounts Unit)

Received By (Name)……………………………………….….Signature………..……………..Date………………..…….
(Registry)

Reviewed By (Name)……………………………………...…..Signature…………….………… Date…..…..……..…….


(Registration Officer)

Verified By (Name)………………………………………….. Signature …………………….… Date …………….……..


(Senior Registration Officer)

Recommended By (Name)………………….……………….. Signature ……………………… Date ……………….…


(Assistant Registrar)

Approved By (Name)……………………….……………….. Signature …………………….… Date… ………………


(Registrar)

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