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NG-KIAMBU CONSTITUENCY DEVELOPMENT FUND

BURSARY APPLICATION FORM 2017/2018


UNIVERSITIES / COLLEGES/SECONDARY SCHOOLS

PLEASE NOTE

1. Application forms are available Free of Charge at the NG-Kiambu CDF office & other designated
points.
2. The following documents MUST be attached to the application form.
a) Fees structure for the current academic year
b) Latest results transcript
c) Death certificate (For Orphans and students whose any of the parents is deceased)
d) Copy of voters card
e) Any other relevant supporting documents
3. The bursary form should be returned to the NG-Kiambu CDF office on or before 9th March 2018

A. PERSONAL INFORMATION
Name of Applicant: ……………………………………………………………………………………………………………………………
Sex: Female ( ) Male ( ) Date of Birth ………………………………………………………………………..
Sub County:. …………………………………………..Ward …………………………………………………………………………………
Location:………………………………………………Sub-Location: ………………………………………………………………………
Address: ……………………………………………….Phone No: …………………………………………………………………………..
B. INSTITUTION INFORMATION
Name of Institution ………………………………………………………………………………………………………………..…………
Reg. /Adm. No. …………………………….…………………Year/Form 1( ) 2( ) 3( ) 4( ) Others …………….
Course taken……………………………………………………………………. Duration ………………………………………………….

C. FEES DETAILS
(a) Fees for the (b) Previous Term/year (s) (c)Amount paid/Able to pay in Balance =
Current Term outstanding balance the current term - Including (a) + (b) – (c)
Funds from Other Financiers

a) Are you a beneficiary of any other bursary? Yes ( ) No ( )

b) Source …………………………………………………… Amount ………………………………………………

D. FAMILY INFORMATION

a) Father’s Name …………………………………………….Occupation……………………… Alive ( ) Deceased ( )


b) Mother’s Name …………………………………………..Occupation …………….………. Alive ( ) Deceased ( )
c) Number of children in the family: …………………………………………………………….……………………………
 How many are in Primary Schools(s)…………………………………………………………….
 How many are in Secondary Schools(s)…………………………………………………………
 How many are in Post Secondary Institutions ………………………………………………
E. DECLARATION

STUDENT’S DECLARATION

I declare that the information given here in is true to the best of my knowledge.
Student Signature ……………………………………………. Date ……………………………………………………………………….

PARENT/GUARDIAN’S DECLARATION

I declare that I understand the contents of this form and that the information given here in is true to
the best of my knowledge and belief
Parent/Guardian’s Signature…………………………………………….. Date ………………………………………………..

SCHOOL’S CERTIFICATION

I confirm that the applicant is a registered student in this school and that the information given here
in above regarding school fees and performance is true

Signature ……………………………………………………..….Date………………………………………………………………….
Name ………………………………………………………….……Designation………………………………………………………
School’s Official Stamp …………………………………………………………………………………………………………………
Remarks ……………………………………………………………………………………………………………………………..........
……………………………………………………………………………………………………………………………………………………
CHIEF/RELIGIOUS LEADER’S CERTIFICATION

I certify that the personal and family information given here in is correct
Signature………………………………………………………..Date……………………………………………………………………
Name……………………………………………………………..Designation ………………………………………………………..
Official Stamp ……………………………………………………………………………………………………………………………..
Remarks ……………………………………………………………………………………………………………………………………..

F. FOR OFFICIAL USE ONLY

BURSARY COMMITTEE RECOMMENDATION

a) Recommended for bursary ( ) Amount awarded ……………………………………………..

b) Not recommended for bursary ( )

Reason(s) …………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………………………..