Last Name: ____________________ First Name/s: ________________________________
Mailing Address: ___________________________________________________________
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Home Telephone Number: ________________________
Mobile Number: ________________________
Work Telephone Number: ________________________
E-mail Address: _____________________________
Age Category: (circle one) 18-25, 26-34, 35-44, 45-54, 65 and above
Marital Status: (circle one) Married/Single/Divorced
Church Affiliation:____________________________________
Position held, if any, in your local church: _____________________________________
Present Employer: _______________________________________________________
List all educational achievements (e.g.. O’Levels, A’Levels; Certificates; Diplomas; Degrees, etc.)
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Signature: ____________________________
Please mail this form to The Registrar, c/o HTC, PO Box EH268, Emerald Hill, Harare, Zimbabwe
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