MUKUBA UNIVERSITY

INSTITUTE OF BIOMEDICAL AND HEALTH SCIENCES

OFFICE OF REGISTRAR
Email: registrar@mukuba.edu.zm
All correspondence to be addressed to the Registrar

APPLICATION FORM FOR ENROLMENT INTO REGISTERED NURSING PROGRAMME

Candidate’s Application No___________________ Receipt No ___________________

Application Fee: K150 (Non -refundable) Date bought __________________

_____________________________________________________________________________________

PART A: APPLICANT’S PERSONAL AND CONTACT DETAILS

1. SURNAME: _____________________OTHER NAMES: ___________________________________
2. NRC No: _____________/____/____ or PASSPORT NO (for non-Zambians) ____________________
3. NATIONALITY: _________________________ SPECIMEN

4. DATE OF BIRTH: Day ____ Month ______________Year __________

5. AGE (attained at last birthday): _______________
6. SEX ___________ M-Male F -Female
7. MARITAL STATUS ________________ M-Married U-Unmarried
8. POSTAL ADDRESS: ________________________________________________________________
_____________________________________________________________________________________
Note: Provide usable postal addresses, which the institution can use for posting acceptance letter.
The institution will not be held liable for wrong postal addresses
9. RESIDENTIAL ADDRESS: ___________________________________________________________
_____________________________________________________________________________________
10. CONTACT NUMBER(S): _________________________Email: ____________________________
11. NAME AND ADDRESS OF PARENTS/GUARDIAN/NEXT OF KIN (Delete which is not
applicable):_________________________________________________________________________
_____________________________________________________________________________________

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Contact Number(s): ____________________________________________________________________
12. HIGH SCHOOL ATTENDED & YEAR OFCOMPLETION_________________________________
____________________________________________________________________________________
PART B: ACADEMIC DETAILS (GRADE (12) TWELVE RESULTS OR ITS EQUIVALENT)
SNO SUBJECT GRADE SNO SUBJECT GRADE
1. ENGLISH 13. COMMERCE

2. MATHEMATICS 14. PRINCIPLES OF ACCOUNTS

3. BIOLOGY 15. LITERATURE IN ENGLISH

4. SCIENCE 16. ADDITIONAL MATHEMATICS

5. CHEMISTRY 17. RELIGIOUS EDUCATION

6. PHYSICS 18. DESIGN AND TECHNOLOGY

7. AGRIC. SCIENCE 19. METAL WORK

8. GEOGRAPHY 20. WOOD WORK

9. HISTORY 21. ART

10. CIVIC EDUCATION 22. NUTRITION

11. HOME ECONOMICS 23. Others

12. FOOD AND NUTRITION 24. Others

PART C – PROFESSIONAL QUALIFICATIONS (PRIOR LEARNING), IF APPLICABLE

(COMPLETE TABLE STARTING WITH THE MOST RECENT QUALIFICATIONOBTAINED)
COLLEGE YEAR NAME OF QUALIFICATION EXAMINING
OR COLLEGE / OBTAINED BODY
UNIVERSITY FROM TO UNIVERSITY
ATTENDED

SPECIMEN

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Note: Attach documentary evidence of qualifications obtained- certified photocopies of certificates and
not originals

PART D: AWARDS RECEIVED (PRE-SERVICE CANDIDATES ONLY)

CATEGORY TICK YEAR AWARDED INSTITUTION

Creativity & innovation (E. g JETS,
Geography Projects etc.)

Leadership related (E. g Prefects,

Head boy/girl, Scripture Union
Leader etc.)

Academic excellence
(E. g Best in Mathematics, biology etc.)

Games (Football, netball, basketball etc.)

Others (E. g Scripture Union

membership and other faithbased
activities, dancing troops, Choir, Cadets,
Marshal arts, Performing arts etc.)

None

Note: Attach documentary evidence of awards e. g certified copy of Testimonial

PART E: PRE-TRAINING EXPOSURE, IF APPLICABLE (COMPLETE TABLE)

CATEGORY INSTITUTION / REMARKS
COMMUNITY
Professionally trained and
qualified
SPECIMEN

Community Health Assistant

Red Cross, Psychosocial

Counseling, Peer Educator etc.

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Classified daily employee at
health facility
Community Health Work (E. g
TBA, CHW, SMAG etc.)
Others

None

Note: Attach documentary evidence of Pre-training exposure e. g. introductory letter where

possible

PART F: PHYSICAL OR COMMUNICATION DISABILITIES

1. Do you have any physical or communication disabilities? (Tick where applicable)

YES

NO
2. If yes, circle the disability applicable:
a. Vision
b. Mobility
c. Speech
d. Hearing
e. Other (Give
details):_______________________________________________________ Explain extent
of disability________________________________________________________

PART G: PERSONAL STATEMENT

Explain why you are applying for this programme, what you hope to learn from it, and how it will
benefit you (Please write with own hand)
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……………………………………………………………………………………………………… SPECIMEN

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PART I – DECLARATION AND SIGNATURE
• I declare that the information I have supplied on this form is to the best of my knowledge
complete and correct. I acknowledge that my application for enrolment is subject to
acceptance by the institution.
• That all documents supplied with this application form are legal and not fraudulently
obtained.
• I further acknowledge that in the event my application for enrolment as a student is
accepted by the institution, I will be bound by the provisions of the relevant Student
statutes, Rules and policies of the institution that are in force and lawful instructions from
institutional authorities.

• That by signing this application form; I fully understand and agree with the above
stipulations.
APPLICANT’S SIGNATURE: .............................................................................................
DATE: ......................./......................../..................
_____________________________________________________________________________
ATTACHMENTS: Please attach the following documents:
1. Pre-Service Candidates
a. Copy of Grade 12 Statement of Results or certificate
b. Certified copy of National Registration Card or Passport (Foreign students)
c. Certified copy of Professional qualification(s)
d. Certified copy of Award(s)
e. Photocopy of supporting documents for Pre-training exposure(s)
f. Photocopy of recommendation letter from Faith-based institution e. g Church, if applicable
g. Latest passport size photo (clear, visible and with no hair extensions)

SPECIMEN

FOR OFFICIAL USE ONLY

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DATE RECEIVED ...................................../..................................../................................................
RECEIPT NO: ...................................................................................................................................
NAME OF RECEIVING OFFICER: ................................................................................................
SIGNATURE OF OFFICER: ................................................................................................................

BANK DETAILS FOR APPLICANTS:

Name of Bank: Investrust Bank ACCOUNT No. 0810356598035
For more information, visit www.mukuba.edu.zm

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