EAST NEW BRITAIN PROVINCIAL ADMINISTRATION

KOKPKPO DISTRICT ADMINISTRATION

Address

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2023 KOKOPO DISTRICT SCHOLARSHIP SCHEME APPLICATION FORM

NEW APPLICANT

Please complete and return the form to the KDSS office with these requirements

1. 2023 Registration copies, 2. Ward member certification Letter, 3. Current Character Reference, 4.
Latest Genuine Certificates/Transcript Copies, 5. Passport Size Photo

A) PERSONAL INFORMATION

NAMED: ______________________ Gender ______ Denomination: _____________________

Home Province: ________________ District: __________________ Village/Town: _____________

B) CURRENT RESIDENTIAL STATUS

Province: _______________ District: ______________ LLG: _________ Ward: _________

C) INSTITUTION/COIRSE DTAILS

Institution: ___________________ Program/Course: _____________________ Year: ___________

D) PARENTAL INFORMATION

Father’ Name: _______________ Occupation: __________________ Home Province: ___________

Mother’ Name: ______________ 0ccupation: ___________________ Home Province: __________

REASON FOR BEING IN THE DISTRICT (F0R PARENT NOT FROM KOKOPO)

E) CONTACT DETAILS: PARENT’S: __________________ STUDENT’S: _________________________

F) OFFICE OF THE LLG USES ONLY DECLARATIONS

I the undersign declare that this is true in nature;
PARENT NAME (1) _________________________ Signature: _______________________
STUDENT NAME (2) ________________________ Signature: _______________________
PASTOR’S NAME: _____________ CHURCH: _________________ Signature: ______________
WARD MEMBER’S NAME: ______________ Ward: ____________ Signature: ________________
LLG PRESIDENT/TOWN MAYOR (Sign): _____________________ LLG COMMON SEAL: _____________