PHOTO

Website: www.wanachuo.com e-mail info@wanachuo.com P.O.Box 62859 Dar Es salaam

East African Student Discount Card Application Form

Payment of 20,000/= can be done through the following Accounts: M-pesa 0767 19 1777, or
Barclays Bank AC No: 011-6004607 AC Name: Brand Computers.
This form should be filled by student and returned to Wanachuo programme through e-mail or
postal address provided above.
1.

Name as appeared in your student ID:

2.

Sex:

Male

Female

3. Date of birth // Nationality:

4.

Home Address:
Country:

Region:

District:

5. Mobile number..Alternative mobile number

6. Your ID type: ID/Registration Number:..
7.E mail:..alternative e mail.
8. Current University/College/School Name & Address:.
P.O.BoxRegion .Country.
Name of Faculty:.
Name of Department:
9.

Family Status:

Never married

Married

10.

Do you have children?

Yes

No

EDUCATION BACKGROUND
11.

Level of Education (mark the appropriate response(s)):

High school

Yes

No

Name of Course/stream/combination: ..
Name of School: _____________________________________________________
Vocational Training: Name

Yes

No

Name of Course: _____________________________________________________

Technical: Name
Yes

No

Name of Course:
Undergraduate/Degree: College

Yes

No

What are your areas of study? __________________________________________

__________________________________________________________________
__________________________________________________________________
Postgraduate: Name....

Yes

No

What are your areas of study? ______________________________________________________

PhD: Name of the College:.
Yes

No

What are your areas of study? ___________________________________________

12. Employment status. Are you employed?

Yes

No

13. Name of the Employer:..Position

14. Mention two hobbies and interests:,.
15. Are you willing to volunteer through Wanachuo programme?

Yes

No

If yes choose area to support:

a. Training

b.Writing Articles

e.Other supports

c.Online support

d.Community support

specify.

16. Suggest the simplest payment mode: M-pesa

Tigo Pesa

Z-pesa

Bank

17. Give us the address of which the card will be delivered to you:
18. Person to be contacted in any situation where we can not reach you.
Name:
Relationship:

Mobile: ..

E mail: .
19. You have been referred to this Programme by: Member reference Number:../2011
20. Your close friend whom you think can be interested with the programme:
Name.e mail.
I thus declare the information provided explain my profile and i have read and agree on term
and conditions for Wanachuo programme membership.
Student Signature.Date..

Wanachuo Programme East Africa, P.O.Box 62859 Dar Es salaam, Tanzania.