REPUBLIC OF KENYA MINISTRY OF EDUCATION, SCIENCE & …

REPUBLIC OF KENYA MINISTRY OF EDUCATION, SCIENCE & TECHNOLOGY

TELEGRAMS: EDUCATION-NAIROBI TELEPHONE: NAIROBI 318581 FAX: 214287

JOGOO HOUSE "B" HARAMBEE AVENUE P.O. BOX 30040 NAIROBI

FORM "A"

NATIONAL, EXTRA COUNTY & COUNTY SECONDARY SCHOOLS BURSARY APPLICATION FOR (SESBAF)

YEAR__________________________ DISTRICT_______________________ LOCATION _____________________ WARD _________________________

CONSTITUENCY___________________________ DIVISION _________________________________ SUB LOCATION ___________________________ VILLAGE/ESTATE_________________________

PART A: STUDENT'S PERSONAL DETAILS

1. FULL NAME ........................... .................................... ...........................

First

Middle

Last

2. Gender...........................

Date of Birth ......................................

3. Admission Number...........................

Form................... Year......................

4. Name of School.............................................................................................

5. Postal Address................................................................................................

For those students joining form I (Please attach joining instructions)

a. School Admitted

National

Provincial

District

Former Primary School Head Teacher's Remarks

b. Student/Pupil Conduct

Excellent

V. Good

Fair

Poor

I declare that to the best of my knowledge the above information is true/or the applicant to attach a copy of certified school leaving certificate.

__________________________ ___________________

Name

Signature

_________________ Date & School Stamp

Address_____________________________________ Mobile No._____________________

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For students either joining Form I or continuing in Form 2, 3, or 4

Total Fees

Paid/able to raise

Outstanding balance

Kshs.

Kshs.

Kshs.

PART B: FAMILY INFORMATION Tick appropriately

Both Parents Dead

One Parent Dead

Both Parents Alive

Single Parent

Any Disability

Attach support documents: e.g (death certificates, letter explaining disability or other disadvantage circumstance from Chief, Religious leader, prominent reference) 1. Father/Guardian's Name ............................................................................ Occupation/Profession................................................Contact....................... 2. Mother's Guardian's Name.......................................................................... Occupation/Profession................................................Contact....................... 3. How many brothers and sisters do you have? .......... 4. How many children does the guardian have? .......... 5. How many are working/in business/farming? .......... 6. How many are in Secondary school? .......... 7. How many are in Post-Secondary Institutions? .......... 8. If both parents are alive, who has been paying for your education? ..........................

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(For continuing students)

Guardian

Sponsor/Well-wishers

Any other (Specify)

9. Have you ever benefited from the Constituency Bursary Fund

Yes

No

10. If Yes, state the amount. Kshs.

EITHER: CHIEF/ASST. CHIEF Comment on the status of the family/parent___________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

I certify that the information given above is correct. Name _______________________________ Signature__________________Date___________

Position/Designation_________________________________ Mobile No. _________________

(Official Stamp) ____________________________________

OR: RELIGIOUS LEADER Comment on the family /parents status ______________________________________________________________________________ ______________________________________________________________________________

Certify that the information given above is correct Name _______________________________ Signature__________________Date___________

Position/Designation_________________________________ Mobile No. _________________

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PART C: INFORMATION ABOUT FAMILY FINANCIAL STATUS.

1. GROSS INCOME IN THE LAST 12 MONTHS (KSHS.)

Father

Mother

Guardian/Sponsor

GROSS

INCOME

Gross income: (This means income from salary, business and farming)

2. APPLICANT'S SIBLINGS IN EDUCATIONAL INSTITUTIONS.

SIBLINGS

NAME OF

NAME/GUARDIANS INSTITUTION

CHILDREN

YEAR OF TOTAL FEES OUTSTANDING STUDY FEES PAID BALANCE CLASS

GRAND TOTAL

PART D: DECLARATION 1. STUDENT'S DECLARATION I declare that to the best of my knowledge the information given herein is true.

Student's Signature...................................................Date.......................

2. PARENT'S/GUARDIAN'S DECLARATION I declare that I have read this form/this form has been read to me and I hereby confirm that the information given herein is true to the best of my knowledge. Parent's/Guardian's Name .................................................Contact ........................ Parent's/Guardian's Signature...................................................Date.......................

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3. SCHOOL VERIFICATION For ongoing students Year

Position in class/for Term I

Term II

Term III

(Attach a Report Form) Student Discipline (Tick one option only)

Excellent

V. Good

Good

Fair

Poor

Head teacher's brief comments on the student's level of need, discipline and academic performance ___________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Head teacher ____________________________________ Signature _______________________

Date and School stamp ____________________________ Mobile No. _____________________ .....................................................................................................................

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