Kmtc Application Template Form – Fill Out and Use This PDF

KMTC/QP-01/CAP

	Telephone: +254-2-2725711/2/3/4	P.O Box 30195
		00100, Nairobi
	Fax: +254-2-2722907
		Kenya
	Website: www.kmtc.ac.ke
		Telegrams. “MEDTRAIN” Nairobi
	Email: admissions@kmtc.ac.ke
	Kenya Medical Training College
	ISO 9001: 2008 Certified	Ref No.____________

APPLICATION FORM FOR PRE-SERVICE CANDIDATES (CERTIFICATE/DIPLOMA PROGRAMMES 2014/2015 ACADEMIC YEAR)

APPLICATION FORM FOR REGULAR CATEGORY APPLICANTS

Please complete this form and send to the Director, KMTC P.O Box 30195 - 00100 Nairobi. The form should be filled in BLOCK letters. Attach copies of results slip/certificates, leaving certificates and ID/Passport/ Birth Certificate/Waiting card. Attach Application Fee in form of a Banking slip or Bankers Cheque of Ksh.1,000 ($50 for Non-Kenyans) Payable to The Director KMTC Account No. 0100358521700 at National Bank Hospital Branch (KNH). You can also pay application fee via M-Pesa (see details in section E of this form).

SECTION A: Applicant’s Personal Particulars

i.Names as per ID/Passport/Birth Certificate…………………………………………………………………………………………

ii.Postal Address…………………………Postal Code……………….........................................Town……………………………..

iii. ID/Birth Cert. No/Waiting Card No…………..……………………………..Gender: Male

Female

iv.Name of next of Kin …………………………………………………..Relationship …………..…….…………….…..………….

v.Nationality………………County……………………District/Sub-County……………………….Constituency………………………

vi.Mobile telephone contact (1) ……………………………………………… (2) ………………………………………………….

SECTION B: Course Application Details: Indicate 2 Choices ONLY in order of Priority:

1st Choice: Diploma in………………………….………………........ 1st Choice: Certificate in………………………………………

2nd Choice: Diploma in……………………………………………... 2nd Choice: Certificate in ……………………………………..

SECTION C:	Applicant’s Education Background:	(Attach copies of certificates)
School Attended……………………………………….Year of Exam……………….Mean Grade/Equivalent………………………
SECTION D:	Disability Assessment:
i Do you consider yourself a person with disability? Yes		No	Type/Class: Physical	Mental

(Please note that disability information is required for planning purposes and not criteria for selection)

ii Give details of the nature of Disability: ……………………………………………………………………………………………

SECTION E: Application fee details

Mode of payment: Banking Slip Bankers Cheque Money Order M-Pesa

Banking Slip/Banker’s Cheque/Money Order No/M-Pesa Ref. No.………………………………………Amount (Ksh).………………

(Note: For those paying via M-Pesa, Go to MPESA on your phone, select lipa na mpesa, select pay bill, enter business number as 964150, Enter your ID number as the account number, then enter amount – ksh.1022, ksh.22 being transaction fee. Wait for a message from M-Pesa and enter the confirmation code in the space above).

SECTION F: Applicant’s Declaration:

I declare that the information given herein is true and accurate to the best of my knowledge and fully understand that any information found to be false will lead to automatic disqualification from consideration and/or prosecution.

Signature of Applicant.……………………................... Date……………………………………………………

THIS FORM IS NOT TRANSFERABLE AND ISSUED FREE OF CHARGE