KIBU/ADMIN.11.30…… KIBABII UNIVERSITY COLLEGE (A Constituent College of Masinde Muliro University of Science and Technology) P.O. Box 1699-50200 Bungoma Kenya Tel: 020-2028660 / 0708-085934 / 0734-831729 E-mail: [email protected] Website: www.kibabiiuniversity.ac.ke STAFF DEPENDANTS APPLICATION FORM FOR SCHOLARSHIP SCHEME 2012/2013 ACADEMIC YEAR This form is to be completed by KIBUCO staff. This is an official document and the information provided must be true and correct to the best of your knowledge. Giving false or incorrect information will lead to automatic disqualification of the applicatio and may further lead to disciplinary aciton of forfeture of bursury if obtained fraudeulently. (Submit 3 copies of the application form and attach fee structure by latest 31st July 2013. 1. PARTICULARS OF STAFF Na e:……………………………………………………………………………………………..PF/NO……………………………………….. Depart e t:………………………………………………………………………Date of 1st Appoi t e t………………………… Employment status (Permanent, Temporary, Contract):…………………………………………………………………….. Telepho e No:……………………………………………………..E ai Address:…………………………………………………….. 2. PARTICULARS OF THE CHILD Na e:………………………………………………………………………………Ge der:………….……………………………………….. Reg. No:………………………………………………………Fa ult /S hool/Ce tre:……………………….………………………… Progra e:……………………………………………………………………..Year of Stud :…………………………………………… Telepho e No:……………………………………………………..Ti k if a JAB/PSSP/E e i g Stude t:…………………….. 3. ANY OTHER INFORMATION (attach documentary evidence for i and ii below) i) Do ou ha e a ala e to pa ? Yes / No…………….. If es state the a ou t……………………………… ii) Has the child deferred his/her University studies? If yes give reasons: Medical/social/Financial/Academic (delete as applicable) 1 iii) Has this child ever benefited from KIBUCO Staff Dependants Scholarship Sheme before? Yes/No:………………………………………………………………………………………………………………………………………. iv) Is this the (1st, 2nd, 3rd, 4th, 5th) time of request for support of this hild/ Choose o e………………… v) Do ou re ei e a If es i 4. fi a ial support fro e er al spo sors? Yes / No: ……………………………………. a o e please spe if …………………………………………………………………………………………………. DECLARATION BY THE STAFF I declare that the information given above is true to the best of my knowledge Na e:………………………………………………………………………ID/NO………………………………………………………………. Sig ature:…………………………………………………………………Date:………………………………………………………………… 5. FOR OFFICIAL USE ONLY Date Re ei ed:…………………………………………………………………………………………………………………………………… Verifi atio Perso el:…………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………….. Na e of Offi er:……………………………………………………….Date: ……………………………………………………………… (KIBUCO Staff Welfare Com ittee eeti g held o :…………………………………………………………………………. A arded Kshs. ……………………………………………………………….. Thruough Mi :……………………………………… If ot a arded gi e reaso s :…………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………………………………………….. Signed: ………………………………………………………………Date:…………………………………………………………………….. Chairman, Staff Welfare Committee 2