REPUBLIC OF ZAMBIA

MINISTRY OF DEFENCE

DEFENCE SCHOOL OF HEALTH SCIENCES

Telephone: +260 211 240556 Plot 119, Kalanga Road
Telefax: +260 211 846057 Emmasdale
E-mail: [email protected] P.O. Box 390022
LUSAKA-ZAMBIA
___________________________________________________________________________________
Application Fee: K200.00 (non -refundable) Receipt No ………………………………..
Date bought ……………………………….
Received by …………………………….….
Date…………………………………...........

APPLICATION FORM FOR ENROLMENT FOR DIPLOMA INTO: -

ADVANCED DIPLOMA IN HIV Nurse PRACTIONER

DIPLOMA IN REGISTERED NURSING
DIPLOMA IN CLINICAL MEDICINE
DIPLOMA IN ENVIRONMENTAL HEALTH TECHNOLOGY

Specify Programme applied for: __________________________________________________________

FOR OFFICIAL USE ONLY:

Candidate’s application no. ______ ______ ____________________

PART A: APPLICANT’S PERSONAL AND CONTACT DETAILS

1. SURNAME: ______________________________ OTHER NAMES: ________________________________

2. NRC No: ____________/______/____ or PASSPORT NO (for non-Zambians) _________________________
3. NATIONALITY: ______________________ 4. SEX ________ M-Male F -Female
5. MARITAL STATUS ________________ M-Married U-Unmarried
6. 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
7. RESIDENTIAL ADDRESS: _____________________________________________________________
8. CONTACT NUMBER(S): ____________________________________ Email: ____________________
9. DATE OF BIRTH: Day ______ Month _______________ Year ___________
10. NAME AND ADDRESS OF PARENTS/GUARDIAN/NEXT OF KIN (Delete which is not applicable):
________________________________________________________________________________________
Contact Number(s):
________________________________________________________________________________________

1
11. HIGH SCHOOL ATTENDED & YEAR OF COMPLETION ___________________________________
________________________________________________________________________________________

PART B: ACADEMIC DETAILS (GRADE 12) TWELVE RESULTS OR ITS EQUIVALENT)

12.
SNO SUBJECT GRADE SNO SUBJECT GRADE
01. ENGLISH 08. RELIGIOUS EDUCATION
02. MATHEMATICS 09. AGRIC. SCIENCE
03. BIOLOGY 10. NUTRITION
04. SCIENCE 11. COMMERCE
05. GEOGRAPHY 12. CHEMISTRY
06. HISTORY 13. PHYSICS
07. CIVIC EDUCATION 14. PRINCIPLES OF ACCOUNTS

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

(COMPLETE TABLE STARTING WITH THE MOST RECENT QUALIFICATION OBTAINED)

13.
LEVEL YEAR NAME OF COLLEGE/ QUALIFICATION EXAMINING BODY
COLLEGE FROM TO UNIVERSITY OBTAINED
OR ATTENDED
UNIVERSITY

PART D: CERTIFICATES RECEIVED

14.
CATEGORY INSTITUTION/COMMUNITY REMARK
Professionally trained and qualified.

Community Health Assistant

Red Cross, Psychosocial Counselling, Peer

Educator etc.
Classified daily employee at health facility

Community Health Work

(E.g. TBA, CHW, SMAG etc.)

Others

Name

NOTE: Attach documentary evidence of Pre-training exposure e.g. Introductory letter, where
possible.

2
PART E: PHYSICAL OR COMMUNICATION DISABILITIES

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

Yes: No:

b. If yes, circle the disability applicable

i. Vision

ii. Mobility

iii. Speech

iv. Hearing

v. Other (Give details)

PART F: PERSONAL STATEMENT

16. 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)
_____________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

3
_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

17. PART G: – 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……...../...................../..................

ATTACHMENT: Please attach the following documents:

Pre-Service Candidates

a. Certified 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 Pre-training exposure(s).
f. Photocopy of recommendation letter from Faith-based institution e.g Church, if applicable.
g. Latest passport size photo.

NOTE: Minimum entry requirement is Five (5) Credits or better in Mathematics, English Language and any
Science being compulsory, and any other two subjects.

4
PART H: – BANK DETAILS

18. Deposit a non-refundable application fee in the School account:

a. BANK NAME: ACCESS BANK

b. ACCOUNT NAME: DEFENCE SCHOOL OF HEALTH SCIENCES
c. ACCOUNT NUMBER: 0120110000067
d. BRANCH: GARDEN BRANCH

19. Present the bank deposit slip and obtain a school accounts’ receipt.
20. Submit the completed application form with attached certified copies of requirements to the
school.

APPLICANT’S SIGNATURE……………………………DATE……......................................................

21. Completed Application Form should be addressed/returned to:-

The Commandant
Defense School of Health Sciences
Plot 119, Kalanga Road
Emmasdale
P.O. Box 390022
LUSAKA

FOR OFFICIAL USE ONLY

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

N.B. APPLICATION FORM MUST NOT BE PHOTOCOPIED.