MARAGUA CONSTITUENCY DEVELOPMENT FUND

BURSARY APPLICATION FORM

SECONDARY / UNIVERSITY / COLLEGE -OCTOBER 2015

(FORM NOT FOR SALE)

Fill in the required information in the spaces provided.

PART A: PERSONAL DETAILS OF STUDENT

  1. Name of the Applicant: ……………………………………………….Reg No. ………………
  2. Permanent Home Address: …………………………Tel No…………………………………
  3. Sex: A Male: B Female
  4. Date of Birth (DD/MM/YY): ……………………………………………………………..
  5. Place of Birth: Village …………………..………Sub-location…………..……………… Ward ………………………Constituency …………………………………………………

PART B: PERSONAL DETAILS OF THE FATHER/MOTHER/GUARDIAN

This section should also apply for applicants who are under the care of a guardian.

  1. Are both your parents alive? 1. Yes ……………. 2. No ……………… (if one or both parents are deceased, attach death certificate(s).
  2. Who takes care of your school fees? A. Father B. Mother C. GuardianD. Sponsor
  3. Name of 7. Above………………..…..…………………Occupation………………………. Tel. No……………………………….
  4. Name of the Father …………………….………….…….. Occupation: ……………………Tel No………………………..
  5. Name of the Mother: …………………………..…………Occupation: ……..………………Tel No.……………………….
  6. Highest level of Father’s/guardian’s education: …………………………………………………
  7. Highest level of Mother’s education: …………………………………………………………….

PART C: FAMILY TYPES AND SIZE

  1. Describe the type of your family: 1. Parents living together 2. Parents have separated 3. Parents have divorced 4. I am a child of a single parent. 5. Other (specify) …………………….
  2. How big is your family? 1. Number of brothers …………. 2. Number of sisters ………………..

PART D: INFORMATION ABOUT YOUR SCHOOL/COLLEGE/UNIVERSITY

  1. Name of your School/College/University: ………………………………………………………
  2. Full address of theSchool/College/University………………Code…………Tel………………
  3. Current Class/Form/Year of study:…………………………………. (attach your result slip/report form and any other document to confirm your student status)
  4. Total outstanding (current) fees balance: Kshs ………………….(attach supporting statement from the school duly signed and stamped by the school authority (registrar/Bursar)
  5. Have you ever applied for CDF bursary before? Yes ……………… No. ………….(tick one)
  6. Have you ever benefitted from CDF bursary before? Yes………. No………………

If yes, (in 21 above,) indicate the year and amount allocated. Year……….. amount…………..

Year ……………Amount Year ……………Amount year …………. Amount …………

  1. Have you ever benefited from any other bursary Yes……………. No …………………………

If yes, indicate from whom ……………………………………………. Year(s) ………… ………………………………amount(s) ……......

PART E: SOURCES AND SIZE OF FAMILY INCOME

  1. Main source of family income? ………………………………………………………………….
  2. Estimated TOTAL monthly family income: Kshs ………………………………………………
  3. If you have brothers and/or sisters in school or colleges, provide the information required in Table below. You must also attach copies of report forms or other supporting documents to confirm the student’s status of the listed siblings.

Brother’s or sister’s Name / Name of school or college/ university / Types of institution
1. Secondary
2. College
3. University / Year of study or form / Education expenses for the last 12 months / Main source of funds

PART F: DECLARATIONS

APPLICANT’S/STUDENT’S DECLARATION:

I declare that the information given herein is true to the best of my knowledge and I am willing and available to verify it if need be. I have also attached all required documents.

Applicant’s full name: ………………………………………Adm/Reg No: ……......

ID No.: ………………Date: ……………………… Signature ………………………………….

FOR OFFICIAL USE ONLY

  1. ASSESSMENT OF THE APPLICANT BY SUB-LOCATION BURSARY COMMITTEE

(Tick as necessary)

Very needy ………. 2. Needy……. 3. Average ……….4. Not needy ……

  1. DECLARATION BY ASSISTANT CHIEF

I confirm that the above student hails from my sublocation

Name…………………………………..Sign…………………………….Date…………………..

Stamp

  1. DECLARATION BY SUBLOCATION BURSARY COMMITTEE

We declare that we know the contents of this application form and hereby confirm that the information herein is true to the best of our knowledge.

Name DesignationSignatureDate

………………………...... Chairman……………………………..

………………………...... Secretary……………………………..

………………………...... Treasurer……………………………..

  1. DECLARATION BY CDF WARD REPRESENTATIVE

I declare that the application form has been vetted

Name……………………….……..……………Sign…………....……………..Date………………

Stamp

NB: Lack of fully completed form and documents will lead to disqualification of applicant.

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