BURSARY APPLICATION FORM . KANGEMA CONSTITUENCY. FOR UNIVERSITY / COLLEGES STUDENTS

APPLICATION FOR KANGEMA CONSTITUENCY BURSARY UNIVERSITY / COLLEGES STUDENTS APPLICATION FORM (Please read through the whole form before starting to fill). Attach Fees Structure, students I.D., and National ID. Student’s Name ………………………………………………………………………................. Reg. No. ……………………………………… Year of Registration ………………………….. National ID.No. ……………………………… Tel: …………………………………………….. Location: ……………………………………. Sub – Location: …………………………………. Year of Study (Tick: 1st, 2nd, 3rd, 4th, Other: …………… Date of Application: ……..................... State whether Regular, Parallel or Private ……………………………………………................. Name of University ……………………………………………………………………………… Course of Study ……………………………………………Duration………………………......... Name of College ………………………………………………………………………………….. Course of Study: ……………………………………………Duration………………………….... Are you a beneficiary of University Loan / Bursary this year (YES/NO) Specify……………….. Amount awarded (If any) Kshs. ………………………………………………………………….. Amount applied for from CDF Kshs……………………………………………………………… Expected completion time: ……………Month ……………………Year ………………………. FAMILY BACKGROUND Name of Parent / Guardian …………………………………………………………………... Sub-Location ………………………………….. Ass. Chief’s Name ……………………….. Location ……………………………………… Chief’s Name ……………………………… Are both parents alive? ………………………………………………………………………. OR One is alive (Specify) ……………………………………………………………………. Any brothers / sisters at other institutions NAME

INSTITUTION

1 2 3 4 5 6 7 8 9 10 What is the total amount that the University expects you to pay per year?............................. ………………………………………………………… (Attach University fees structure)

Attach school’s identity card. Student’s Occupation (if any) ……………………………………………………………… STUDENT DECLARATION OR GUARDIAN I certify that the information given above is true to the best of my knowledge. Name: ………………………………………………………………………………………… Signature: …………………………………………. Date: ……………………………………………… ASSISTANT CHIEF’S I certify that the person named above is from my Sub-location and is a University student. Comments: …………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………… Assistant Chief’s Name ………………………………………………………………………. Signature ……………………………………………………………………………………... Official Stamp and Date ……………………………………………………………………… CDF SUB-LOCATION CHAIRMAN I certify that the person named above is from my sub-location and is a University student. Comments: …………………………………………………………………………………………………… …………………………………………………………………………………………………… ………………………………………………………………………………………… PMC Chairperson’s Name:……………………………………………………………………. Signature……………………………………………………………………………………….. Official Stamp and Date………………………………………………………………. Date returned to PMC Chairperson…………………………….Sign……………………. NB: 1. False information will lead to disqualification and / or prosecution 2. Fully filled forms to be submitted to Sub Locational PMC Chairman’s Offices. FOR OFFICIAL USE ONLY Amount applied ………………………………………………………………………………. Amount granted ……………………………………………………………………………… Remarks …………………………………………………………………………………………………… …………………………………………………………………………………………………… Signature of Officer in Charge: …………………………………………………………… Date: ………………………………………………………………………………………….