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‫ب م ل ر م رح م‬
                                    ِ ‫ِسْ ِ ا ّ ال ّحْ َنِ ال ّ ِي‬
   THE UNIVERSITY OF DODOMA MUSLIM STUDENTS ASSOCIATION
                                UDOMSA
                    P.O.BOX 1160 DODOMA
Email; udommuslim@yahoo.com/udommuslim@gmail.com
       www.udomsa.blogspot.com or www.udomsa1.blogspot.com


                          STUDENT MEMBERSHIP REGISTRATION FORM
                                                                    FORM NO: ________________
FULL NAME: _______________________________________________ ____________ _____________________
DEGREE PROGRAME: __________________________________________________ [         AFFIX           ]
REGISTRATION NUMBER:-_T/UDOM/___________________________                  [                   ]
PLACE OF DOMICILE (Tick as appropriate): TANZANIA MAIN LAND ( ),         [ PASSPORT            ]
TANZANIA ZANZIBAR ( )                                                     [                   ]
SPONSORSHIP (Tick appropriate) PRIVATE { } GOVERNMENT{ }                  [                   ]
               Means Test Grade_____ -% ____                              [     HERE          ]
PERSONAL DETAILS                                                          [_______________ __]
SIR NAME__________________________               FIRST NAME___________________________
MIDDLE NAME______________________
DATE OF BIRTH___________________GENDER SEX ;( Tick appropriate) MALE ( ) / FEMALE ( )
ADDRESSES:
*PERMANENT ADDRESS                               * CURRENT ADDRESS
 P.O.BOX_______________                           P.O. BOX ___________________
 ________________________                          ___________________________
 ________________________                          ___________________________
TELPHONE NUMBER(S):
1. _________________________    2. _________________________ 3._______________________________
FAX NUMBER: ________________________
________________________________________________________________________________________________
ACADEMIC BACKGROUND:
    LEVEL                         NAME OF SCHOOL                     PLACE
- PRIMARY EDUCATION          ________________________________,     ____________________________.
- SECONDARY (O-LEVEL) _________________________________,            ____________________________.
- SECONDARY (ADVANCE) _________________________________,           _____________________________.

OTHER ACADEMIC QUALIFICATION(Tick as appropriate)
CERTIFICATE{ }              DIPLOMA { }            ADVANCED DIPLOMA {      }
OTHER (Specify) ______________________________________________________

LEADERSHIP EXPERIENCE:                    POST                PLACE                   YEAR
                          ______________________________   _____________________     ________
                         ______________________________   ______________________     ________
                         ______________________________   ______________________    _________
RELIGIOUS STUDIES ATTAINED:
__________________________________________________________________________________________________

MARITAL STATUS (Tick as appropriate)
SINGLE { }                           MARRIAGE {   }


    PAGE 1 of 2             Authorized by Department of Publicity and Relation –UDOMSA 2010®

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REGISTRATION FORM YA UDOMSA

  • 1. ‫ب م ل ر م رح م‬ ِ ‫ِسْ ِ ا ّ ال ّحْ َنِ ال ّ ِي‬ THE UNIVERSITY OF DODOMA MUSLIM STUDENTS ASSOCIATION UDOMSA P.O.BOX 1160 DODOMA Email; udommuslim@yahoo.com/udommuslim@gmail.com www.udomsa.blogspot.com or www.udomsa1.blogspot.com STUDENT MEMBERSHIP REGISTRATION FORM FORM NO: ________________ FULL NAME: _______________________________________________ ____________ _____________________ DEGREE PROGRAME: __________________________________________________ [ AFFIX ] REGISTRATION NUMBER:-_T/UDOM/___________________________ [ ] PLACE OF DOMICILE (Tick as appropriate): TANZANIA MAIN LAND ( ), [ PASSPORT ] TANZANIA ZANZIBAR ( ) [ ] SPONSORSHIP (Tick appropriate) PRIVATE { } GOVERNMENT{ } [ ] Means Test Grade_____ -% ____ [ HERE ] PERSONAL DETAILS [_______________ __] SIR NAME__________________________ FIRST NAME___________________________ MIDDLE NAME______________________ DATE OF BIRTH___________________GENDER SEX ;( Tick appropriate) MALE ( ) / FEMALE ( ) ADDRESSES: *PERMANENT ADDRESS * CURRENT ADDRESS P.O.BOX_______________ P.O. BOX ___________________ ________________________ ___________________________ ________________________ ___________________________ TELPHONE NUMBER(S): 1. _________________________ 2. _________________________ 3._______________________________ FAX NUMBER: ________________________ ________________________________________________________________________________________________ ACADEMIC BACKGROUND: LEVEL NAME OF SCHOOL PLACE - PRIMARY EDUCATION ________________________________, ____________________________. - SECONDARY (O-LEVEL) _________________________________, ____________________________. - SECONDARY (ADVANCE) _________________________________, _____________________________. OTHER ACADEMIC QUALIFICATION(Tick as appropriate) CERTIFICATE{ } DIPLOMA { } ADVANCED DIPLOMA { } OTHER (Specify) ______________________________________________________ LEADERSHIP EXPERIENCE: POST PLACE YEAR ______________________________ _____________________ ________ ______________________________ ______________________ ________ ______________________________ ______________________ _________ RELIGIOUS STUDIES ATTAINED: __________________________________________________________________________________________________ MARITAL STATUS (Tick as appropriate) SINGLE { } MARRIAGE { } PAGE 1 of 2 Authorized by Department of Publicity and Relation –UDOMSA 2010®