You are on page 1of 7

KIAMBU TOWN CONSTITUENCY DEVELOPMENT FUND

P.O BOX 1767 00900


KIAMBU
CONDITIONS
1) The form must be fully filled.
2) The requested attachment must be attached.
3) Any omission of the above 1 or 2 shall lead to automatic disqualification.
4) The fully filled form should be returned to the CDF Office as per the dates
specified.

UNIVERSITY/COLLEGES/SECONDARY BURSARY
APPLICATION FORM 2014/2015
STUDENTS RESIDENTIAL DETAILS
DISTRICT
DIVISION
LOCATIONSUBLOCATION.
WARD.VILLAGE/ESTATE

PART A: STUDENTS PERSONAL DETAILS


1. FULL NAME

..
Last
First
Middle
2. Sex

Male( )

Female ( )

3. Date of Birth.Adm.
No..Class.
4. Day scholar ( )

Boarder ( )

THE BURSARY FORM SHOULD BE RETURNED TO THE KIAMBU TOWN C.D.F OFFICES ON OR
BEFORE 2ND MARCH 2015
1

5. Address.Telephone
.
6. Attach a photocopy of Institution ID (For Colleges & Universities)

INSTITUTION INFORMATION
1. Full Name of University / College/ Secondary school (Do not write in initials)

.
2. Institution Functional addressTelephone
number

PART B: FAMILY INFORMATION


1) Tick Appropriately
a. Both parents deceased
b. One parent deceased
c. Both parents alive
d. Single parent
e. Any disability
(Attach supporting documents e.g. death certificate, letter explaining
disability or other disadvantage/circumstance from chief or religious
leader, prominent reference).
Fathers/guardians
name
Occupation
/Profession

Mothers /Guardians
name
Occupation /
Profession
.
2) How many brothers and sisters do you have?
THE BURSARY FORM SHOULD BE RETURNED TO THE KIAMBU TOWN C.D.F OFFICES ON OR
BEFORE 2ND MARCH 2015
2

3) How many children does the guardian have?


4) How many are working/in business/farming?
5) How many are in secondary schools?
6) How many are in post-secondary institutions?
7) If both parents are not alive, who has been paying for your education? (Tick)
a) Guardian
b) Sponsor/Well wishers
c) Any other (specify)
8) Have you ever benefited from the Constituency Bursary Fund or CDF bursary?
Yes

Amount Awarded

No
If yes indicate Year awarded
9) Indicate assistance from any other sources: Yes
If yes indicate: Ministry of Education
Year awarded

No
County Council

Amount

TERTIARY COLLEGES AND SECONDARY SCHOOLS ONLY


Total annual
fees

Amount
paid
...
Amount requested from
CDF
(ATTACH AN APPROVED FEE STRUCTURE AND A CURRENT REPORT FORM)

CHIEF/SUBCHIEF/RELIGIOUS LEADER
Comment on the status of the
family/parents
THE BURSARY FORM SHOULD BE RETURNED TO THE KIAMBU TOWN C.D.F OFFICES ON OR
BEFORE 2ND MARCH 2015
3

.
I certify that the information given above is correct
Name..Signature
.Date.
Position/Designation
..
Address.Telephone

PART C: INFORMATION ABOUT FAMILY FINANCIAL STATUS


1. GROSS INCOME IN THE LAST 12 MONTHS (KSH)
FATHER

MOTHER

GUARDIAN/SPONSOR

GROSS
INCOME
*Gross Income: (This means income from salary, business and farming)

2. APPLICANTS SIBLINGS IN EDUCATIONAL INSTITUTIONS


SIBLINGS
NAME/GUARDIAN
S CHILDREN

NAME OF
INSTITUTION

YEAR OF
STUDY/CL
ASS

TOTAL
FEES

FEES
PAID

OUTSTAND
ING
BALANCE

THE BURSARY FORM SHOULD BE RETURNED TO THE KIAMBU TOWN C.D.F OFFICES ON OR
BEFORE 2ND MARCH 2015
4

GRAND TOTAL

PART D: DECLARATION
1. STUDENTS DECLARATION
I declare that to the best of my knowledge the information given herein is true.
Students
signature..Date
..

2. PARENTS/ GUARDIANS DECLARATION


I declare that I have read this form / this form has been read to me and hereby
confirm that the information given herein is true to the best of my knowledge.
Parents /Guardians
name..
Parents/Guardians
signature.Date..
Parent/Guardian telephone
number

3. UNIVERSITY/COLLEGE VERIFICATION
(a) For continuing students
Year of
study

Students discipline (Tick one option only)


Excellent ( ) V. Good ( ) Good ( )

Fair ( )

Poor ( )

LOAN INFORMATION FOR UNIVERSITY STUDENTS


Total fees for the current academic
year
Amount given as loan by
HELB
Amount awarded from HELB as
bursary...
THE BURSARY FORM SHOULD BE RETURNED TO THE KIAMBU TOWN C.D.F OFFICES ON OR
BEFORE 2ND MARCH 2015
5

Amount the beneficiary can


raise
..
Amount requested from CDF.
.
Any other sponsor (if any)

(Attach an approved copy of the institutions fee structure)


Dean of Faculty/Principals of colleges and secondary school brief comment on the
level of need, discipline and academic performance.

I declare that the above named is a student in this University /College / Secondary
School.
Dean/Principals
Name

Signature.
.
Date and institutions
stamp
..

PART E: FOR OFFICIAL USE ONLY BY THE CONSTITUENCY


BURSARY COMMITTEE

APPROVED FOR BURSARY

NOT APPROVED FOR BURSARY

THE BURSARY FORM SHOULD BE RETURNED TO THE KIAMBU TOWN C.D.F OFFICES ON OR
BEFORE 2ND MARCH 2015
6

..
.
Bursary awarded Ksh.

REASONS FOR NOT APPROVING

Chairmans
Name.Signature.Date

Secretarys
Name.Signature.Date
..
Official Stamp

THE BURSARY FORM SHOULD BE RETURNED TO THE KIAMBU TOWN C.D.F OFFICES ON OR
BEFORE 2ND MARCH 2015
7