Love and Knowledge USAMBARA GIRLS SECONDARY SCHOOL, P. O. BOX 517, KOROGWE – TANZANIA E. AFRICA PHONE: +255 768 519 397 +255 767 066 746 +255 688 655 183 FORM No. ____________ Date: 21/01/2014 APPLICATION FORM FOR FORM FIVE (5) 2014 USAMBARA GIRLS SECONDARY SCHOOL, OFFERS THE FOLLOWING COMBINATION: HGL (History, Geography, English Language). To qualify for form five (5) at Usambara Girls Secondary School, a student must have obtained Division 1 (One), 2 (Two) or 3 (Three) in her Form Four (4) certificate of Secondary Education Examinations with grade A, B or C in the subjects she wishes to study. Please fill out and return this form to Usambara Girls Secondary School as soon as possible. REQUIREMENTS: 1. A photocopy of the “O” Level Examinational Result Slip 2. Character Assessment Form from the former head of school 3. Tshs. 20,000/= for this application form. (Non-refundable) 4. You are required to report to “Usambara Girls Secondary School” on 29/03/2014 at 8:00am for interview. ………………………………. Sr. Domitila Mshahara HEADMISTRESS APPLICANT’S DETAILS PLEASE WRITE IN CAPITAL LETTERS PHOTO PARENT/GUARDIAN DETAILS 1. 2. 3. 4. 5. PARENT/GUARDIAN’S NAME: _______________________ NATIONALITY:____________ OCCUPATION: __________________________________ TELEPHONE:__________________ FULL CONTACT ADDRESS: ______________________________ TOWN:________________ RELATION TO APPLICANT: _____________________________________________________ RELIGION: __________________________________ DENOMINATION: _________________ PARENT’S GUARDIANS SIGNATURE: ________________________ DATE: _______________ STUDENT’S DETAILS 6. STUDENT’S FULL NAME: ___________________________ (AS IT APPEARS IN CSEE) 7. DATE OF BIRTH: _______________________________ PLACE: _______________________ 8. NATIONALITY: _________________________________ TRIBE: ________________________ 9. RELIGION: _____________________________________ DENOMINATION: _____________ 10. HOME ADDRESS: ______________________________ TOWN: ________________________ 11. O-LEVEL SCHOOL: _____________________________ REGION: ______________________ 12. ADDRESS: ______________________________________________________________________ 13. CSEE INDEX NUMBER _____________________ YEAR: __________ 14. FORM FOUR (CSEE) RESULTS: SUBJECT GRADE CIVICS KISWAHILI ENGLISH HISTORY GEOGRAPHY BIBLE KNOWLEDGE AGRICULTURE SUBJECT BASIC MATHS BIOLOGY PHYSICS CHEMISTRY LIT.ENGLISH COMMERCE BOOK-KEEPING TOTAL POINTS AWARDED: ______________ GRADE DIVISION: ________________ Combination for which you are applying: Tick (√) one HGL Return the complete application form immediately together with the other require Documents. If you meet the requirements, you will be invited to join Form V in our School, APPLICANT’S SIGNATURE: ______________________ DATE: _____________ FORM No. ____________ USAMBARA GIRLS SECONDARY SCHOOL P. O. BOX 517, KOROGWE CHARACTER ASSESSMENT FORM: (This form should be filled by THE FORMER HEAD OF SCHOOL and be returned to Usambara Girls Secondary School immediately ) Name of student: ________________________________ Examination number:_________ Name of School: _________________________________ Headmistress’ /Headmaster’s Name: ________________________ Phone:_______________ (Please circle one) 1. The student shows respect for others (teachers, students) by her actions i.e being polite, gentle, follows instructions: (a) always (b) Often (c) sometimes (d) rarely (e) never 2. The student volunteers to help with extra work: (a) always (b) often (c) sometimes (d) rarely (e) never 3. The student skips classes: (a) always (b) often (c) sometimes (d) rarely (e) never 4. The student has been involved in truancy from school: (a) always (b) often (c) sometimes (d) rarely (e) never 5. The student observes dress code (smartness, full school uniform): (a) always (b) often (c) sometimes (d) rarely (e) never 6. The student observes punctuality: (a) always (b) often (d) sometimes (d) rarely (e) never 7. (a) The students has been sent home due to discipline problem: (i) NO (ii) YES (b) If the answer is YES please give reason ___________________________________ 8. (a) Has the student been involved in one of the following; FIGHTING, STEALING, CHEATING, FORGERY, MISDEMEANORS: (i) NO (ii) YES (b) If the answer is YES please elaborate: _____________________________________ 9. The student participates in co-curricular activities (e.g. clubs, games and sports, debate, school teams, choir etc): (a) Very good (b) Good (c) Fair 10. The student has a serious sickness which hinders her from attending classes daily (i) YES (ii) NO 11. The general conduct of the student is characterized as: (a) Excellent (b) Very good (c) Good (d) Poor Comment: ________________________________________________________________ Headmistress’ / Headmaster’s Signature __________ Official Stamp___________ Date: ___________ After filling this form, please kindly seal the envelope personally and sign across the seal. The information in this form is CONFIDENTIAL. We will appreciate if you could post this recommendation to us at the above address. If this is not possible the student may bring the letter making sure that it is well secured, sealed and stamped with the official stamp, signed across. We would be grateful if this reaches us before the day of the interview on the 29th March 2014 We thank you for your co-operation. May God bless You. ……………………………….. Sr. Domitila Mshahara HEADMISTRESS