2023 CENSUS DECLARATION FORM

FIRST NAME: LAST NAME:

ID/PASSPORT: CITIZENSHIP:

GENDER: Female Male TELEPHONE:

DECLARATION UNDER OATH (IN ENGLISH)

I ________________________________________________________ here by declare that I reside at the following

physical address ________________________________________________________________________________

which is in _____________________________________________________________ constituency, in the

________________________________________ region.

Are you a learner or student? No Yes (Full-time) Yes (Part-time) Yes (Distance)

Are you employed (either on a full or part-time basis)? Yes No

Have you ever been convicted of a criminal offence? Yes No

(if yes, elaborate)

I know and understand the contents of the above declaration. I declare that to the best of my knowledge and belief, all
particulars I have given are complete and true. I understand that any false declaration or misleading statement or any
significant omission may disqualify me from employment and render me liable to dismissal.

Date: ________/________/ 2023 Signature:

(Deponent)

I certify that the statement was read back and the deponent has acknowledge that he/she knows and understands
the contents of this statement which was sworn to/affirmed before me and the deponents signature was placed
thereon in my presence.

Name: _____________________________________

STAMP
Signature: __________________________________ COMMISSIONER OF OATH

Date: ________/________/ 2023