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Intern Pharmacist Registration Form

APPLICATION FOR PROVISIONAL REGISTRATION AS AN INTERN PHARMACIST

(Section 18(1) and (2) of the Pharmacy Act. Cap 311).

Required fields are marked with*.

Applicants are reminded to register their names as they appear in Ordinary Certificate of Secondary Education (CSEE) and Advanced Certificate of Secondary Education (ACSE).

PART I: (To be completed by the applicant)

*First Name

Middle Name

*Last Name

Sex*

*Mobile Phone (Tafadhari andika nama yoyote isipokuwa namba ya halotel inasumbua kupokea namba ya Mtihani)

*Email

Date Of Birth*

*National ID Number (NIDA No.)

*Postal Address

*Region

*Physical Address

*Nationality (Awarding University/College)

*Awarding University/College

*Year of Graduation

*Qualification