Form hn 21-Data Capture Tools-07-3-2019 - Huduma Namba

Section 1

CONFIDENTIAL

FORM: HN001

DATE

DD MM YY Y Y

Serial Number:

DIGITAL DATA CAPTURE FORM

(If a child's Age < 6yrs ll the Bio Data Information, Birth Certi cate /Noti cation Entry No, Parent's Details and Exit!)

Bio Data Information

First Name

Name:

Middle Name

Surname

Other Names

Digital photo

Gender: ( ) Male

( ) Female

Place of Birth Details

Country:

County:

Sub-County:

Date of Birth: D D MM Y Y Y Y

Division:

Location:

Sub-Location:

Disability Are you living with disability? ( ) Yes ( ) No

Citizenship Information

If yes, specify:

Disability Registration Number

I I I I I I I I

Citizen

Non- Citizen

ID/NO.

I I I I I I I I

NHIF NO.

I I I I I I I I

NSSF NO.

I I I I I I I I

O. Nationality:

I I I I I I I I

Country of Origin:

Driver's Licence NO.

Passport NO.

Alien ID. No./Refugee NO.

IIIIIIII IIIIIII I I IIIIIII I I

KRA PIN NO.

I I I I I I I I

(Expiry date)

(Expiry date)

D D MM Y Y Y Y

D D MM Y Y Y Y

Passport NO. I I I I I I I I I

(Expiry date) DD MM Y YYY

Marital Status

Spouse Details

( ) Single ( ) Married ( ) Separated ( ) Divorced ( ) Widowed

Spouse Name First Name

1. 2. 3. 4. 5.

Parents/Guardian Details

Father's Name :

First Name

Middle Name

Mother's Name:

First Name

Guardian

First Name

Individual

Name:

Guardian Institution

Name:

Middle Name Middle Name

Name

Status: ( ) Work Permit ( ) Special Pass ( ) Dependant Pass

( ) Pupil Pass ( ) Intern

( ) Refugee

( ) Asylum

( ) Stateless ( ) Other

Middle Name

Surname

ID/Passport No.

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

Surname Surname Surname

( ) Deceased

( ) Alive

I I I I I I I I ID/No./

Passport No.

I I I I I I I I ( ) Deceased ID/No. /

( ) Alive

Passport No.

I I I I I I I I ( ) Deceased ID/No. /

( ) Alive

Passport No.

I Registration No. I I I I I I I I

Section 2

Huduma Namba Registration is mandatory as per Section 9A of the Registration of Persons Act (Cap.107). It will enable the Government to provide you with services. This form and the registration process is absolutely free of charge.

Section 3

Section 4

Permanent Physical Address/Home Address

County:

Sub-County:

Division:

Location:

Sub-Location:

Village/Estate/House No.

Current Physical Address County:

Sub-County:

Division:

Location:

Contact Details Postal Address:

Sub-Location: Postal Code:

Education Details

Level of Education (tick the highest level) ( ) Pre-primary ( ) Primary ( ) Secondary ( ) Vocational ( ) Middle level colleges ( ) Undergraduate ( ) Postgraduate Other:__________________________________________

Village/Estate/House No.

Primary Phone Number

I I I I I I I I

Email Address:

If currently studying, which level? ( ) Pre-primary ( ) Primary ( ) Secondary ( ) Vocational ( ) Middle level colleges ( ) Undergraduate ( ) Postgraduate Other:_________________________

NEMIS No:

IIIIIII I I

Employment Status

( ) Employed ( ) Self-Employed ( ) Unemployed

( ) Retired ( ) Casual

Agricultural Activities

Are you engaged in agricultural activities? ( ) Yes ( ) No .............................................................................................................................. If yes specify: ( ) Fish Farming ( ) Tree Farming

( ) Crops

( ) Livestock

Do you practice irrigation?

( ) Yes ( ) No

Type of Industry:

If Self-Employed:

( )Large ( ) Medium

( ) Service ( ) Industrial ( ) Agricultural ( ) Small & Micro (SME)

What is the Land tenure/Ownership status?

( ) Leased ( ) Community

( ) Private ( ) Public Land

What is the size of the farm? ( ) below 5 acres ( ) 10-50 acres ( ) 5-10 acres ( ) 50-100 acres ( )over 100 acres

Biometric Details Digital Fingerprints:

Right Index

Right Ring

Section 5

Section 6

Section 7

Right Thumb

Right Middle

Right Little

.R..e.s.p.o.n..d.e.n..t:.............(..).S..e.lf.......(..).P.a..re.n..t....(..)..O.t.h.e.r..................................................................

If other

First Name

Middle Name

Surname

ID/No./ Passport No.

IIIIIII I I

Disclaimer:

a

systems. I understand that my information may be provided to an authorised Government agency/agencies.

Agree

Digital Respondent's Signature

or Digital Respondent's Le Thumb Print

First Name

Name

Middle Name

Surname

Signature, Stamp and Fingerprint:

Remarks:

Should the space provided on this form be insu cient, ll the additional information on a white A4 sheet of paper and attach to this form. Write the Registration Number of this form at the top of any additional sheets.

2

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