Empowering for Self-reliance

NATIONAL GOVERNMENT AFFIRMATIVE ACTION FUND.

BURSARY AND SCHOLASHIP APPLICATION FORM.
1. DETAILS OF LOCALITY
NAME OF COUNTY…………………………….COUNTY CODE………………
CONSTITUENCY………………………………..WARD…………………………
2. PERSONAL AND SCHOOL DETAILS
NAME OF STUDENT…………………………………CLASS/FORM…………
ADMISSION NO……………………………..YEAR OF STUDY………………
DATE OF BIRTH……../……./…………
NAME OF SCHOOL/INSTITUTION……………………………………………..

3. WHERE APPLICABLE INDICATE

NAME OF FATHER………………………………………PHONE………………
CURRENT OCCUPATION………………………………………………………..
NAME OF MOTHER…………………………………….PHONE………………..
CURRENT OCCUPATION…………………………………………………………
GUARDIAN……………………………………………PHONE…………………
FAMILY INCOME LEVEL (MONTHLY IN
KSH.)……………………………………………………………………………...

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 4. PERSONAL STATUS
(APPLICANT TO TICK ONE)
ORPHAN AND NOT SUPPORTED BY EXTENDED FAMILY
……………………………
ORPHAN BUT SUPPORTED BY FAMILY/SPONSOR
……………………………
PERSONS WITH DISABILITY
(PWDS)…………………..
SINGLE PARENT FAMILY……………………
OTHER STATUS (PLEASE EXPLAIN)…………………………………………
………………………………………………………………………………………
………………………………………………………………………………………

NOTE: PLEASE PROVIDE SUCH EVIDENCE (RELEVANT

CERTIFICATES/LETTERS FROM LOCAL CHIEF ETC) AS MAY BE
APPROPRIATE AND WHERE APPLICABLE TO SUPPORT YOUR
STATUS.

5. PERSONAL STATEMENT
(NOTE: LEARNER TO EXPLAIN WHY BURSARY IS SOUGHT)
……………………………………………………………………………………..
……………………………………………………………………………………..
……………………………………………………………………………………..
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 6. FEES DETAILS
FEES PAYABLE ANNUALLY………………………………………………….

CURRENT FEE BALANCE……………………………………………………..

AMOUNT REQUESTED FOR………………………………………………….

NOTE: IT IS MANDATORY TO ATTACH FEES STATEMENT-

STAMPED AND SIGNED BY THE SCHOOL.
IN THE CASE OF NEW STUDENT, ATTACH ADMISSION
LETTER.

7. CONFIRMATION OF FEES AND PERSONAL STATUS

LOCAL ADMINISTRATOR (CHIEF/ASS-CHIEF) TO VERIFY AND
CONFIRM.
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NAME OF OFFICER………………………………………………………….

SIGNATURE………………………………..DATE………………………….

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8. FOR OFFICIAL USE ONLY
BURSARY APPROVED (Yes/No)……..........AMOUNT…………………………

COMMENT…………………………………………………………………………
………………………………………………………………………………………
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………………………………………………………………………………………

CHAIRPERSON………………………….SIGN……………DATE……………..

SECRETARY…………………………….SIGN……………..DATE……………

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