REGISTRATION FORM FOR BEING A LEADER AND THE EFFECTIVE EXERCISE OF LEADERSHIP COURSE

TO BE HELD AT KENYATTA UNIVERSITY CONFERENCE CENTRE

19TH FEBRUARY 2018 – 25TH FEBRUARY 2018

INSTRUCTIONS: Please answer each question clearly and completely

•Read carefully and follow all directions.

•This is a word document you can type directly, save and send it back as an attachment to: or write in capital letters, scan the pages and send it back by email or post it to the address given in the letter;

•If you need more space, attach additional pages.

•PERSONAL DATA:

•Family name (Surname) / •First name / •Middle name, if applicable
• Nationality / •Gender
Male ------
Female ------
•Permanent Address / •Present Address if different from that indicated in box 6
•Telephone numbers
Home------
Mobile------
Work------/ •Personal email
------
Professional email
------

B. EDUCATION BACKGROUND:

Please give the exact titles of degrees and diplomas obtained.

UNIVERSITY OR EQUIVALENT

NAME PLACE AND COUNTRY / FROM
MO/YEAR / TO
MO/YEAR / DEGREES and ACADEMIC
DISTINCTIONS OBTAINED / MAIN COURSE OF STUDY

OTHER FORMAL TRAINING OR EDUCATION e.g. high school, technical school or diploma level training)

NAME, PLACE AND COUNTRY / TYPE / ATTENDED FROM/TO / CERTIFICATES OR
DIPLOMAS OBTAINED
Mo/Year / Mo/Year

C. KNOWLEDGE OF LANGUAGES:

LANGUAGES / READ / WRITE / SPEAK / UNDERSTAND
Easily / Not Easily / Easily / Not Easily / Fluently / Not Fluently / Easily / Not Easily
Swahili
English
Others

D. EMPLOYMENT RECORD:

Tick whichever is applicable to you

I am self-employed------I am a Member of County Assembly of------

I am a Member of Parliament from------

I am an entrepreneur ------

I am employed by: ------

E. If Employed, what is your title and responsibilities in your current job?

------

F. What is the Mission and Vision of the Institution/Organization which has employed you?

------

G. PREFERENCE FOR YOUR HOTEL OCCUPANCY:

Please mark your preference occupancy

------I am booking for a single room occupancy

------I am booking for a double room occupancy (sharing a room)

H.PAYMENT OPTIONS

Select your tuition/boarding payment option from the table below:

Rates Early birds- Sharing – Not sharing – dates for early bird
Single Rooms (not sharing) Kshs. 60,225.00 only (tuition and boarding) ($602.25USD)
Double occupancy (sharing) Kshs. 45,500.00 only (tuition and boarding) ($455USD)
Option 1: Payment in one instalment
•Pay before 30th of November in one instalments for single occupancy and get a discount of Kshs. 9,650.00 only ($96.50USD)
•Pay before 30th November in one instalment for double occupancy and get a discount of Kshs. 5,000.00 only ($50USD)
Option 2: Payment in 3 instalments
•Single occupancy
Payments in instalments does not attract any discounts and will be paid as follows:-
•1stinstalment of Kshs. 30,000.00 only ($300USD)
•2ndinstalmentKshs. 20,000.00 only (200USD)
•3rd instalment 10,225.00 only ($102.25USD)
•Double occupancy
Payments in instalments does not attract any discounts and will be paid as follows:-
•1stinstalmentKshs. 20,000.00 only ($200USD)
•2ndinstalmentKshs. 15,000.00 only ($150USD)
•3rdinstalmentKshs. 10,500.00 only ($200USD)

NB: All payments must be in by 15th of January 2016.

•COMMITMENT FOR ATTENDING THE BAL TRAINING:

I am committing myself;

•To be responsible for all my travel expenses to the training venue

•To be responsible for my medical insurance during my stay for the residential training

•To read all pre-course material

•To undertake pre-course assignments as directed by the Lecturers

•To attend all classroom sessions as per the programme provided by the Lecturers

•To participate in all course work assignments given during the training

•To work in groups during lunch breaks and in the evenings as directed by the Lecturers

I have read and agree to all of the above

______Accept to participate in the BAL Training

______Decline to participate in the BAL Training

Names: ------

Signature: ------

Date------

NB: Account Details:

You will receive details of the bank account number after you return your registration form.