Full Name *

Birth Date *

in G.C

Age *

Gender *MaleFemale

Nationality *Please select an optionEthiopianAbroad

Marital StatusSingleMarriedOther

Phone Number *

Email Address

Permanent Address *

City

Postal Code

Place of Birth

Program *Degree

(Degree) B.Sc. Program Applied ForBachelor of Science in NursingBachelor of Medical Laboratory ScienceBachelor of Pharmacy

Branch6-KiloSefere Selam

Mode of Study *Regular

Academic Year *

Student ID (If there)

High School Name *

Year Ethiopian Higher Education Entrance Examination Completed *UEE completed year (eg: 2016)

Ethiopian Higher Education Entrance Examination Result *

Highest Qualification Obtained

Relevant Certifications

Blood Group

Medical Conditions

Vaccination RecordAttachedNot Attached

Emergency Contact • Name *

Relationship

Contact Phone Number *

Contact Phone Number2

Address

Copy of Birth Certificate *

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Copy of National ID/Passport *

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High School Academic Transcripts *

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Grade Eight Result Certificate *

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Ethiopian Higher Education Entrance Certificate Examination *

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Passport-size Photographs *

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Medical Clearance Certificate

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COC Certificate

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COC Certification Year

COC Ver. Code

Letter of Work Experience

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Application Fee

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Pay Application Fee __ ETB to College's CBE Account Number: _________ & upload the slip.

Other Documents (If any)

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Are you currently employed *YesNo

Employing OrganizationGovernmentalNon-GovernmentalPrivate

• Name of Employing Organization

Organization Telephone

Organization Address

Declaration *I hereby declare that all the information provided is true and correct to the best of my knowledge. I agree to abide by the rules and regulations of the College of Health Sciences.* Fields are mandatory

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