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Application form for new students

You are requesting admission to the following programme: Distance Bachelor of Science in Clinical Medicine
Please complete the following form entirely to successfully complete your application. Click on the steps below to continue.

1 - General information

In this section you will provide basic information needed for your enrolment.

Information Input fields Description
1.2 - NRC or Passport
Please enter the ID number provided on your national identification card or passport
1.3 - First Name Your given name
1.4 - Middle name Optional
1.5 - Surname Your family name
1.6 - Sex (Gender)  
1.7 - Date of Birth Minimum age for applicants is 16 years
1.8 - Nationality  
1.9 - Streetname and number For example: Munkoyo Street 1583
1.10 - City/Town Example: Kabwe
1.11 - Phone Number For example: 0978168860
1.12 - Email Address Mandatory
1.13 - Country of Residence  
1.14 - Any Medical Condition?
1.15 - Intake  
1.16 - Delivery method