COUNTY GOVERNMENT OF HOMA-BAY

COUNTY PUBLIC SERVICE BOARD

APPLICATION FOR EMPLOYMENT FORM

REPUBLIC OF KENYA HOMA-BAY COUNTY

Please complete this form in BLOCK letters as appropriate and submit the HARD copy to the Secretary,
Homa-Bay County Public Service Board,
P.O. BOX 95, 40300 HOMA-BAY, KENYA,
Website :www.psbhomabay.go.ke

1. Vacancy applying for

Vacancy/post:.....................................................................Vacancy No...................................................................
Department................................................................................................................................................................

2. Personal Details

First Name (Surname)...........................................Other Names...............................................................................

Date of Birth...../......../.............Gender Male Female
Nationality...........................County...........................Sub-County..............................Ward.....................................
ID/Passport No:.....................................Postal Address................................Home Town........................................
Tel No:........................................Mobile No...................................e-mail address...................................................

3. Other Details

Indicate the language(s) you are proficient in (1).......................(2)......................(3)...............................................

Do you suffer from any disability? Yes No

If yes give details.......................................................................................................................................................

Have you ever been convicted of any criminal offences ? Yes No
If yes give details.......................................................................................................................................................

Have you been dismissed or otherwise removed from employment Yes No

If yes, state reason(s) for dismissal/removal............................................effective date..../..../..................................

Have you ever been interviewed by public service of Homabay before? Yes No

If yes state the post................................................................interview date....../......./..............................................

(Declaring the above information will not necessarily debar an applicant from employment
in Public service, an applicant is considered on merit).

For any enquiry please e-mail us on recruitment@psbhomabay.go.ke or call us on

0718841612/0731212009
4. Academic/technical qualification(starting with the highest)

Attainment
Year University/college/ (e.g Courses Specialization Class/Grade
Institution/School Phd,Masters,Degree, (e.g Medicine,
Diploma, Nutrition e.t.c)
Certificate)
From To

5. Registration/membership to professional Bodies/Institution

Year Institution/Professional Body Membership Number Status: Active/Inactive

For any enquiry please e-mail us on recruitment@psbhomabay.go.ke or call us on

0718841612/0731212009
6. Employment details (starting with the most recent)

Year Employer’s Name Position/Rank/Designation

From To

7. Please give details of your abilities, skills and experience which you consider are relevant to the position applied for.
The information may include an outline of your most recent achievements and your reasons for
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For any enquiry please e-mail us on recruitment@psbhomabay.go.ke or call us on

0718841612/0731212009
8. Personal References

The names of distinguished persons should not be used unless they really know you well; the names of relatives or
of those from whom you send testimonials should not be used. The names of staff or Members of the Public Service
Board of Homa-Bay ( Board Members) should also not be used.

1. Full name......................................................................................................................... .........................

Address.....................................................................................................................................................
Tel No:..................................................................E-mail address:...........................................................
Occupation................................................................................................................... .............................
Period for which he/she has known you:.................................................................................................

2. Full name.................................................................................................................... .............................

Address................................................................................................................................... .................
Tel No:..................................................................E-mail address:..........................................................
Occupation................................................................................................................... ............................
Period for which he/she has known you:.................................................................................................,

Declaration:

I hereby certify to the best of my knowledge that the particulars given on this form are correct and i understand that any
incorrect information may lead to automatic disqualification/legal action.

Date ......../........../........... .................................... ....................

(dd/mm/yyyy) Signature of the applicant

For any enquiry please e-mail us on recruitment@psbhomabay.go.ke or call us on

0718841612/0731212009