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    Internship Form Uth v1.2

    Uploaded by

    focevot850
    Intern ship

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Internship Form Uth v1.2

    Uploaded by

    focevot850
    3 views2 pages
    Intern ship

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

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    Intern ship

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    3 views2 pages

    Internship Form Uth v1.2

    Uploaded by

    focevot850
    Intern ship

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 2

    SRL NO.

    UTH/AF/01/2015________
    FORM: UTH/AF/01
    To be filled in triplicate: (Applicants can fill in
    more than one form where necessary)

    1. Original - Applicant
    2. 1st Copy – Approving Authority
    3. 2nd Copy – Finance
    4. 4th Copy – Applicants File

    MINISTRY OF HEALTH
    UNIVERSITY TEACHING HOSPITAL

    INSTITUTE INTERNSHIP/STUDENT ATTACHMENT APPLICATION

    1. INSTITUTION INFORMATION
    NAME OF INSTITUTION

    PHYSICAL ADDRESS CONTACT PERSON


    NAME:
    PHONE NUMBER POSITION:

    PERIOD OF INTERNSHIP FROM: ___/___/20__ PHONE NO.:


    BEING APPLIED FOR TO: ___/___/20__ EMAIL ADDRESS:

    2. PROGRAM INFORMATION
    NO PROGRAM NAME NO. ENROLLED ACADEMIC ANY COMMENTS THAT ARE
    . STUDENTS STATUS*a CONSIDERED IMPORTANT BY THE
    APPLICANT
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    2
    3
    4
    5
    6

    3. INTERNSHIP PROPOSAL
    NO PROGRAM NAME AREA OF FROM TO NO. OF FEE PAYABLE PER
    . ATTACHMENT (DATE) (DATE) STUDENTS MOU
    TO BE
    ATTACHED
    1
    2
    3
    4
    5
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    9
    10
    TOTALS

    a* Academic status means level of qualification such as Certificate, Diploma, Degree, Masters, or
    Doctorate. If not any of these kindly indicate appropriate status.

    Page 1 of 2
    4. DECLARATION

    I............................................................ being the authorised representative hereby certify that the details above
    are correct and there’s no intention to mislead or misrepresent the facts, and uphold that the institution will
    adhere to the conditions as agreed in the Memorandum Of Understanding signed between the two institutions.

    OFFICIAL DATE STAMP


    Full Name: ........................................................
    Position: ........................................................
    Signature: ........................................................
    Phone No. :.......................................................

    .........................................................................................................................................................................................
    FOR OFFICIAL USE ONLY
    A. FINANCE
    INSTITUTION CONTRIBUTION ATTACHEMENT FEE
    PAID: (YES / NO)

    AMOUNT (K)

    RECEIPT NO.

    IS AMOUNT CORRECT AND


    VERIFIED (YES / NO)
    COMPLETED BY: NAME:
    OFFICIAL DATE STAMP

    SIGNATURE:

    DATE:

    B. AUTHORISATION
    Following a careful consideration of your application and clearance given by the finance department your
    application is hereby approved/ Not Approved*. If disapproved you are kindly advised to contact the
    undersigned.

    Name:..................................................... Signature:................................................

    OFFICIAL DATE STAMP

    Page 2 of 2

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