THE INSTITUTE OF FINANCE MANAGEMENT WEEK-END COLLEGE REVIEW CLASSES FOR THE NATIONAL BOARD OF ACCOUNTANTS AND AUDITORS EXAMINATIONS APPLICATION FORM FOR JUL – NOV 2012 FOR OFFICIAL USE ONLY RECEIPT NUMBER DATE OF RECEIPT AMOUNT REGISTRATION AND TUITION FEE Subjects: _______ _________ _______ _______ ________ ________ ADMISSION NUMBER: NBAA/_____________________________ INSTRUCTION 1. This form is to be completed with the applicant and sponsor/employer 2. The applicant should return the form with two passport size photosone stamped on the space provided the other for an identification card. 3. The form should be given back with registration and tuition fees. 4. If the applicant will be sponsored by an organization, the organization’s nominating official should fill and stamp in section VI 5. All payments should be made to The Institute of Finance Management Bank Account: CRDB; PPF TOWER BRANCH DAR ES SALAAM A/C NO: 01J1042984102 Payment slip should be taken to: IFM BLOCK A, Third Floor, Room 320 I REVIEW STAGE – LEVEL/MODULE – APPLIED FOR (Please tick the appropriate) STAGE CLASS Accounting LEVEL I Technician LEVEL II Foundation MODULE A MODULE B Intermediate MODULE C MODULE D Final MODULE E MODULE F NAME OF THE STAGE AND LEVEL/MODULE YOU ARE APPLYING FOR: _______________________________________________________ II APPLICANTS PERSONAL PARTICULARS SURNAME ___________________________________________ FIRST NAME:_________________________________________ MIDDLE NAME: ______________________________________ DATE OF BIRTH:______________________________________ SEX: ___________________PLACE OF BIRTH:_____________ MARITAL STATUS:___________________ NATIONALITY:_________________________ ADDRESS: _____________________________________________ TELEPHONE NUMBERS: __________________________________ E-MAIL ADDRESS: ______________________________ PERSON TO BE NOTIFIED IN CAE OF EMERGENCY: NAME: ____________________________________________ ADDRESS: ___________________________________________ TELEPHONE NUMBER (S) ________________________ III. EDUCATION BACKGROUND NAME OF SCHOOL CERTIFICATION YEAR OF COMPLETION IV. PROFESSIONAL QUALIFICATIONS (FOR PRE-QUALIFIED APPLICANTS) NAME OF QUALIFICATION YEAR OF INSTITUION OR COMPLETION BOARD V. APPLICANT’S SERVICE PARTICULARS (FOR IN –SERVICE APPLICANTS) CURRENT EMPLOYER:______________________________ DEPARTMENT/SECTION: ___________________ POSITION: ______________________________ EMPLOYEMTN ADDRESS: ____________________ TELEPHONE NUMBERS: ________________ E- MAIL ADDRESS: _________________________ VI. SPONSOR’S CERTIFICATION (IF ANY) THE UNDERSIGNED (NAME OF SPONSOR): __________________________ AND ON BEHALF OF (NAME OF AGENCY OR ORGANIZATION): ______________________________________ AND IF ACCEPTED, UNDERTAKE TO PAY FOR ALL THE EXPENSES RELATED TO THE COURSE SIGNATURE:_________________ DATE: ____________ (OFFICIAL STAMP) VII. APPLICANT’S DECLARATION I CERTIFY THAT ALL THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF. FULL NAME OF APPLICANT: _____________________ SIGNATURE: _________________________ DATE: ______ Further information may be obtained in person or in writing from: The Coordinator, Week-end College Shaaban Robert Street IFM Block A, Ground Floor, Room G.20 P.O. Box 3918, Tel.(022) 2112931-4 Fax (022) 2112935 DAR ES SALAAM