Innovation

Excellency

AFRICAN CENTRE FOR GLOBAL HEALTH

Partnerships and
Collaboration

INNOVATION AND RESEARCH (ACGHIR)

APPLICATION FORM
FILL THE APPLICATION FORM IN CAPITAL LETTERS USING EITHER BLUE OR BLACK INK ONLY

1) FOR OFFICIAL USE ONLY

1:1 DATE OF RECEIPT .……/..……/…….. 1:3 AMOUNT PAID $...............................

1:2 RECEIPT NO …….…….……….… 1:4 ASSIGNED CANDIDATE N0………………

2) PERSONAL DATA

2:1 SURNAME ………………………………………………………………………………………………………………………………..

2:2 FORENAME ………………………………………………………………………………………………………………………………

2:3 DATE OF BIRTH e.g DAY/MONTH/YEAR…………………./……./………

2:4 MARITAL STATUS…………………………………………………………………………………………………………………………

2:5 PLACE OF BIRTH…………………………………………………………………………………………………………………………..

2:6 SEX……………………………………………………………………………………………………………………………………………….

2:7 ID NUMBER………………………………………………………………………………………………………………………………….

2:8 a RACE…………………………………………………………………………………………………………………………………

2:8 b NATIONALITY………………………………………………………………………………………… (attach certified copy of ID)

2:8 c ARE YOU A PERMANENT RESIDENT OF ZIMBABWE? Yes (Y) / No (N)…………………………………………

2:9 RELIGION…………………………………………………………………………………………………………………………………

2:10 CANDIDATE ADDRESS

……………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………

2:11 CONTACT DETAILS Cell Number…………………………………………………………………………………………...

Other contact Number……………………………………………………………………………

Email Address………………………………………………………………………………………….

⮚ NB: ALL CORRESPONDENCE WILL BE FORWARDED TO THE ABOVE ADDRESS

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 Innovation
Excellency

AFRICAN CENTRE FOR GLOBAL HEALTH

Partnerships and
Collaboration

INNOVATION AND RESEARCH (ACGHIR)

2:12 NEXT OF KIN DETAILS

2:12:1 SURNAME …………………………………………………………………………………………………………………………..

2:12:2 FORENAME …………………………………………………………………………………………………………………………

Cell Number…………………………………………………………………………………………...

Other contact Number……………………………………………………………………………

Email Address………………………………………………………………………………………….

2:13. PROGRAMME CHOICES

2.13:1 First Preference: Programme

................................................................................................................................................

2.13:2 Second Preference Programme

......................................................................................................................

2.13:3 Third Preference Programme

...............................................................................................................................................

3) SCHOOL EXAMINATIONS FOR WHICH RESULTS ARE KNOWN

DATE EXAMINING LEVEL eg O, A, SUBJECT RESULT / GRADE

BODY eg Oxford, Scottish Higher,
Cambridge etc

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 Innovation
Excellency

AFRICAN CENTRE FOR GLOBAL HEALTH

Partnerships and
Collaboration

INNOVATION AND RESEARCH (ACGHIR)

4) SCHOOLS ATTENDED ( or College or Polytechnic at which school-leaving examinations were
taken)

4:1 PRESENT SCHOOL OR LAST SCHOOL ATTENDED………………………………………………………………………

…………………………………………………………………………………………. INDICATE COUNTRY IF OUTSIDE ZIMBABWE

PERIOD OF ATTENDANCE START YEAR (eg 2009) ……………………………………….

ENDING YEAR (eg 2012) …………………………………….

4:2 SECOND LAST SCHOOL ATTENDED …………………………………………………………………………………………..

INDICATE COUNTRY IF OUTSIDE ZIMBABWE
…………………………………………………………………………………………

PERIOD OF ATTENDANCE START YEAR (eg 2009) ……………………………………….

ENDING YEAR (eg 2012) …………………………………….

5) FURTHER RELEVANT INFORMATION/REMARKS ON EMPLOYMENT/ WORK EXPERIENCE

DATE OCCUPATION NAME AND ADDRESS OF

EMPLOYER
FROM TO
MONTH YEAR MONTH YEAR

6) RECOMMENDATIONS BY EMPLOYER

6:1 NAME OF ORGANIZATION………………………………………………………………………………………………………

6:2 POSITION HELD……………………………………………………………………………………………………………………….

AFRICAN CENTRE FOR GLOBAL HEALTH INNOVATION AND RESEARCH (ACGHIR)Page 3

 Innovation
Excellency

AFRICAN CENTRE FOR GLOBAL HEALTH

Partnerships and
Collaboration

INNOVATION AND RESEARCH (ACGHIR)

6:3 NAME OF EMPLOYER IN (FULL)………………………………………………………………………………………………

6:4 DO YOU RECOMMEND THE ABOVE MENTIONED TO ATTEND THE COURSE? YES/NO…………….

6:5 SIGNATURE…………………………………………………………………………………………………………………………….

7) NAMES AND ADDRESSES OF TWO REFEREES

1) ………………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………

2) ………………………………………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………………………………………….

8) PROSPECTIVE SPONSOR (S) ( eg self; or employer; Please state name)

……………………………………………………………………………………………………………………………………………………….

8:1 PAYMENT CAN BE IN USD CASH OR RTGS EQUIVALENT SWIPE

9) HAVE YOU ENCLOSED CERTIFIED COPIES OF YOUR

A) BIRTH CERTIFICATE
B) NATIONAL ID
C) O-LEVEL CERTIFICATES
D) A-LEVEL CERTIFICATES
E) PROFESSIONAL CERTIFICATE
F) PROFESSIONAL DIPLOMA
G) PROFESSIONAL DEGREE
H) PhD
I) OTHER CERTIFICATE (S) ( specify )

I SOLEMNLY DECLARE THAT THE INFORMATION I HAVE GIVEN IS CORRECT AND SHOULD IT BE
FOUND TO BE FALSE MY APPLICATION WILL BE DISQUALIFIED AND I WILL BE READY TO FACE LEGAL
ACTION

SIGNATURE OF APPLICANT ………………………………………………….. DATE ………………………………

AFRICAN CENTRE FOR GLOBAL HEALTH INNOVATION AND RESEARCH (ACGHIR)Page 4

 Innovation
Excellency

AFRICAN CENTRE FOR GLOBAL HEALTH

Partnerships and
Collaboration

INNOVATION AND RESEARCH (ACGHIR)

FOR OFFICIAL USE ONLY

VERIFIED BY NAME ………………………………………………………………………………………………….

SIGNATURE ……………………………………………………………………………………………

DESIGNATION ………………………………………………………………………………………..

APPROVED BY NAME ………………………………………………………………………………………………….

SIGNATURE ……………………………………………………………………………………………

DESIGNATION ………………………………………………………………………………………..

ACCEPT REJECT

TICK WHERE APPROPRIATE

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