COUNTY GOVERNMENT OF KERICHO P.O BOX 112-20200 KERICHO KERICHO COUNTY BURSARY APPLICATION FORM 2015 ……………………………………………………….ward 1. Applicant MUST be a bonafide resident of Kericho county 2. Application forms shall be obtained from ward offices or downloaded from the county website www.kericho.go.ke 3. Duly filled forms shall be taken to the ward offices by the applicants on or before 21st January 2015 4. The ward bursary committee panel shall forward all the vetted applications forms in order of merit as per the given criteria to the county bursaries management board for disbursement of funds 5. Application forms must be accompanied with copies of : a. National ID where necessary b. Academic certificates /report card/KCPE/KCSE/Current transcripts 6. Authenticated document showing admission/registration number 7. Names of successful and unsuccessful applicants(with reasons) shall be displayed for public viewing at the chiefs office, sub-county offices and county offices 8. Bursary cheques will be released directly to respective institution BUT not individuals` 9. Any applicant found to have given FALSE information shall automatically be disqualified 1 PART A: STUDENT CURRENT PHYSICAL ADDRESS Sub county………………………………………………………………………. Ward……………………………………………. Location………………………… Sub location………………………………………….. Village………………………………………………….. PART B: STUDENT PERSONAL DETAILS (Fill where appropriate) 1. Full Name (Official Name) ……………………………………………………… 2. Date of Birth…………………………………………………………………… 3. Gender …………………………………………………………………….. 4. Admission or Registration Number……………………………………… 5. ID No/Passport……………………………………………………………………. 6. Name of Institution (Attach copy of previous banking slip)/Admission letter……………………………………………………………. 7. County where the institution is located………………………………. 8. Mobile No. of (a) Applicant…………………………………………… (b) Guardian/Parent……………………………………… 9. Are you a (a) Regular student? ………………………………………… (b) Privately sponsored student? ………………………….. PART C: FAMILY INFORMATION 1. Name of Parent/Guardian………………………………………………….. 2. Occupation …………………………………………………………… 2 3. Both Parents alive: Yes ………………………….. No ………………………..(If no attach death certificate or letter from the Chief). 4. Single Parent. Yes …………………. No………………………… 5. a) Any disability: Yes …………………. No……………………….. b) If YES, state the nature of disability………………………………………. 6. If orphan who provides for your school fees? Self……………………..Guardian …………………Sponsor………………… Any other ……………………… 7. Have you benefited from ANY bursaries before? Yes …………………. No………………… (If YES state the source and amount (a) CDF…………………… (b) Ministry…………………… (c) County…………………….. (d) Any other………………….. PART D: APPLICANTS SIBLINGS IN EDUCATIONAL INSTITUTIONS 3 Siblings Names Name of Year of Institution Study/ Form/ class Total Annual fees Fees Paid Outstanding Fees Arrears PART E: STUDENT DECLARATION I…………………………………………………………………. declare that to the best of my knowledge the information given herein is true Signature ……………………………………. Date ……………………………………………… PART F: PARENT/GUARDIAN DECLARATION I declare that I have read this form/it has been read to me and I hereby confirm that the information given herein are to the best of my knowledge true. Name ………………………………………………………. Signature …………………………………………Date ………………………………………. PART G: VERIFICATION BY INSTITUTION. 4 1. To be filled, signed and stamped by the institutional authority Total fees required HELB or other assistance Kshs: Kshs: Amount the student is able to pay Kshs: Outstanding balance Kshs: Bursar/Finance officer signature………………………… School/college Official rubber stamp ……………………………. Signature ……………………………………… Date……………………………… PART H: DECLARATION BY INSTITUTION I declare that………………………………………is a bonafide student of this institution. Name ………………………………………………………………………….. Designation …………………………………………………………………. Phone Number …………………………………………………………….. Official Rubber Stamp ……………………………. 5 PART I: FOR OFFICIAL USE ONLY WARD BURSARY COMMITTEE/PANEL Score …………………………………………………………. Bursary awarded Ksh .…………………………………………………………………… Bursary not awarded (Reasons)…………………………………………………………. Chairperson …………………………..Signature ……………Date…………………… Secretary …………………………….. Signature ……………Date…………………… Ward administrator………………..Signature ……………Date…………………… Official ward stamp…………………………………….. 6