New Democrats House, Tudor Estate, P.O. Box 43428, 80100, Mombasa

NEW DEMOCRATS

New Democrats House, Tudor Estate, P.O. Box 43428, 80100, Mombasa.

Tel: +254 (041) 470230 / +254 (041) 470250 Website:

APPLICATIONFORM FOR

NOMINATIONOFA MEMBER OF COUNTY WOMEN REPRESENTATIVE

New Democratshouse,

Tom Mboya avenue,

P.O Box43428–080100

Mombasa

Tel:0412225708

Fax:0412223633

SCHEDULE1

APPENDIX TWO

THE NEW DEMOCRATS

APPLICATIONFORMFORNOMINATION AS A WOMEN REPRESENTATIVE.

(To BeCompleted in Triplicate)

To: SECRETARY

THE NATIONAL ELECTIONS BOARD

NEW DEMOCRATS,

P.O BOX 43428-080100

MOMBASA

PARTA

I, …………………………………………………………………………….. do hereby apply to be nominated as the NewDemocrats candidate for WOMEN REPRESENTATIVE tocontest intheforthcoming General Elections in…….……………………………………………….……………………………………………………………………………………County.

1. Party MembershipNo ………………………………………………………………

2. Electors CardNo ……………………………………………………………………

3. National Identity CardNo ………………………………………………………….

4. Physical Address…. …………………………………………………………………

5. Postal Address……………….. …………………………….……………………….

6. Telephone……………..………………………………………………………………

7. Email Address………………………………………………………………………

8. Sublocation……. ………………………...………………………………………….

9. Ward...………………………………………………………………………………..

10. Constituency…….. …………………………………………………………………..

11. County…...……………………………………………………………………………

PART B:PARTICIPATION IN PARTY AFFAIRSANDPROGRAMMES

1. Areyou aLifeMembership oftheparty?What isyourLifeMembership No?……………

2. Provide evidenceofyourparticipation in themanagement ofpartyaffairs inyourBranch/Sub branch/Ward?………………………………………………………………………………..

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3. Areyou amemberofanyorgan oftheparty?……………………………………………….

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4. Pleasedemonstrateyourabilityto articulateanytwo objectives ofthepartymanifesto …...

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5. Brieflystateyour commitment and passion to theparty, its ideology, policies and programs.

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6. Canyoubedescribedasadisciplinedanddependablepartymember?Pleaseillustrateinnot morethan two hundredand twentywords.

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PARTC:

1. Brieflystatetheroleyouhaveplayed in therealization ofthenew constitution oftheRepublic ofKenya,OkoaKenyainitiative, VoterRegistration and current ElectoralReforms

2. ProvideevidenceofyourperformanceinthepoliticsofKenyameasuredagainstthefollowing keyachievements:

• Haveyou everbeen elected as aMemberofNationalAssemblyat onestage? YES/NO

• Served as a Member of the senate assembly? YES/NO

• Served as achairoramemberofaCountyAssemblyCommittee? YES/NO

• Served in anycapacityintheNational Assembly? YES/NO

• Served in aresponsibleposition in thepublicservice? YES/NO

3. Wouldyou describeyourself as:

a) An inspirational, transformative and servant leader?

b) A team player

4. Provide evidenceof

i. Commitment in promotingdemocracyand humanrights?

ii. Commitmenttopatriotismreconciliationandnationalcohesionandunityof theKenyan people

iii. Commitment to affirmative action.

5. Demonstrateyourabilityto mount asuccessful campaign (in not morethan500 words).

…………………………………………………………………………………………………

6. Commitment:- please note that by signing this application, I do hereby bind myself to pay

a monthly contribution of Kshs:50,000/=(kenya shillings fifty thousand only) to the party (New Democrats) In the event of winning the seat of member of paliamentat the Senate Assembly.

PARTD:LEADERSHIPAND INTEGRITY

1) AreyouaStateand/orPublicOfficer(ifyouhavebeenaPublicOfficer,showevidenceof resignation)?………………………………………………………………………………..

2) Haveyouatanytimewithinfiveyearsimmediatelypreceding thedateofelection,held office as amemberofaCommission?……………………………………………………...

3) HaveyoubeenaCitizenofKenyaforatleasttenyearsimmediatelyprecedingthedateof elections?…………………………………………………………………………………….

4) Haveyou everbeen declared bankrupt?…………………………………………………….

5) Haveyou everbeen convicted in a court oflaw ona criminal offence?……………………

6) Haveyoueverbeenfoundguiltyinacourtoflawofmisuseofabuseorabusedastateor publicofficeorinanywayto have contravened Chaptersixofthe constitution?………….

7) Demonstrateyourcapacityto mount asuccessfulparliamentarycampaign

PARTE

Pleasesubmit your application withthe following

1) ANon-refundable nomination fee of Kenya Shs One hundredThousand (Ksh.

100,000) or Kenya Shillings ONE hundred Thousand (Ksh.75,000) for youths, and PersonswithdisabilitypayablebyBankersChequeToNEWDEMOCRATSordirect depositto NATIONALBANK OF KENYA LTDAccountNumber01020066097100

NKRUMAH ROAD-MOMBASA.

2) A detailed Curriculum Vitaeindicating amongst otherqualifications the following: - a) Education qualifications.

b) Experiencein themanagement ofpublic affairs.

3) A copyofyoureducational qualifications

4) A copyofyourNationalIdentification Card

5) A copyofyourElector’sCard

6) AcopyofyourNEW DEMOCRATSLifeMembershipCertificate

7) Dulycompleted, signed and witnessed CodeofConduct Form;

8) Dulycompleted, signed and witnessed PledgeofCommitment Form;

PARTF

1) I confirmIhavenot sought Nomination from anyother registered Political Parties

(YES/NO)

2) IconfirmthatIhaverevokedmynominationbyotherregisteredPoliticalPartieswhichI

had earlieron sought nomination

(YES/NO)

Candidateto tick(YES/NO)whichever is applicable.

DatedAt………………………This………………………Day of……………………..2016

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SIGNATURE

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FULLNAMESOFCANDIDATE

NB:Pleasesubmit yourapplication with a copyof thereceipt for theapplication fees dulypaid.

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ForOfficial Useonly

Information VerifiedBy:………………………………………Date……………………… Received at thePartyHeadquarters……………………………..Date……………………… ApprovedBy………………………………………………….. Date…………………….. ComplianceCertificateNo. ……………………………Issued On ……………………..