Kas Secondary Bursary Form

Serial No.
FY- 2019/2020
NATIONAL GOVERNMENT CONSTITUENCIES DEVELOPMENT FUND

OFF OYUGIS - KISUMU ROAD Visit our Website P.O Box 264 - 40222 OYUGIS
OPPOSITE OYUGIS POLICE STATION Website: www.cdf.go.ke E-mail: [email protected]
SECONDARY SCHOOLS BURSARY APPLICATION FORM

INSTRUCTIONS TO APPLICANTS
1. This application form is issued FREE OF CHARGE by Kasipul NG-CDF Office
2. Applicant must attach I.D. and voter’s card photocopies of parents /guardian.
3. Applicant must attach COPY of current report form.
4. Bursary awarded is not transferable by the beneficiary.
5. Approved bursary awards will be paid directly to the Institution and cannot be converted to cash payments to the applicant.
6. If single or both parents are dead, you must attach support document e.g. burial permit / death certificate.
7. Disability e.g. physically challenged: You must attach support document, letter explaining disability or other disadvantages
and circumstance.
8. The needs for all beneficiaries will be considered on application and canvassing is prohibited.
9. Cheating if detected, will lead to automatic disqualification.
10. All the information provided will be cross-checked against information from other official public sources.
11. You are required to fill in all appropriate spaces as provided.
12. Bursary application forms NOT dully filed will NOT be accepted.
13. Students joining FORM ONE MUST provide calling /admission letter and a Leaving School Certificate from the immediate
former Primary School signed and endorsed with an official stamp.
PART A: STUDENT’S PERSONAL DETAILS
FULL NAME _______________________ _________________________ ______________________

First Middle Last
LOCATION __________________ SUB LOCATION_________________ VILLAGE_______________
WARD_______________________ POLLING STATION ______________________________________
GENDER: MALE ( ) FEMALE ( ) DATE OF BIRTH ______________________________
PART B: SECONDARY SCHOOL PARTICULARS
Name of School______________________________________________________________________
National County/Extra County Sub County Special
Admission Number__________________ Form__________________ Year__________________
Postal Address_____________________________________________________________________
Page 1 Kasipul NG-CDF | Secondary Schools Bursary Application Form |

For those students joining form I (Please attach joining calling/ admission letter)
Former Primary School Head Teacher’s Remarks
Student/Pupil Conduct Excellent V. Good Fair Poor
I declare that to the best of my knowledge the above information is true/or the applicant to attach a copy of
certified school leaving certificate.
__________________________ ___________________ _________________
Name Signature Date & School Stamp
Address_____________________________________ Mobile No._____________________
PART C: BURSARY REQUEST
Total Fee Payable per Year’ Kshs’__________________ Amount Able To Raise’ Kshs’__________________
Amount Requested ‘Kshs’__________________ (Attach the Fee Statement)
Have you ever benefited from the Constituency Bursary Fund?

Yes No If Yes, state the amount Kshs.
PART D: PARENT’S / GUARDIAN’S DETAILS

Tick appropriately
Both Parents Alive_______ Partial Orphans_________
Total Orphans____________ Single Parent____________ Any Disability _____________
(If one or both parents are deceased, attach death certificate(s) and evidence of any disability)
Name of Father_____________________________ Occupation______________________ Contact_______________
Name of Mother_____________________________ Occupation ______________________ Contact______________
Name of Guardian____________________________ Occupation ______________________Contact______________
Physical/ Postal /Permanent Address___________________________________________

Attach support documents: e.g (death certificates, letter explaining disability or other disadvantage
circumstance from Chief, Religious leader, prominent reference)
How many brothers and sisters do you have? _______ How many children does the guardian have? _____
How many are in Secondary school? _______ How many are in Post-Secondary Institutions? _____

PART E: INFORMATION ABOUT FAMILY FINANCIAL STATUS.
1. GROSS INCOME IN THE LAST 12 MONTHS (KSHS.)
Father Mother Guardian/Sponsor

Gross Income
Gross income: (This means income from salary, business and farming)
2. APPLICANT’S SIBLINGS IN EDUCATIONAL INSTITUTIONS.

Siblings Name of Year of Outstanding
Name/Guardians Children Institution Study Class Total Fees Fees Paid Balance
Grand Total
PART F: CERTIFICATION BY EITHER: CHIEF, ASSISTANT CHIEF OR RELIGIOUS LEADER

Comment on the status of the family/parent____________________________________________________
_______________________________________________________________________________________
I certify that the information given above is correct.
Name _______________________________ Signature __________________Date___________
Position/Designation_________________________________ Mobile No. _________________
(Official Stamp) ____________________________________
PART G: DECLARATION/ VERIFICATION

1. STUDENT’S DECLARATION
I declare to the best of my knowledge that the information given herein is true.
Student’s Signature……………………………………………... Date…………………..
2. PARENT’S/GUARDIAN’S DECLARATION
I declare that I have read this form/this form has been read to me and I hereby confirm that the information
given herein is true to the best of my knowledge.
Parent’s/Guardian’s Name ………………………….…………… Contact ……………………
Parent’s/Guardian’s Signature……………………………….…… Date………………………..

3. SCHOOL VERIFICATION
For ongoing students
Student Academic Performance (Tick one option only)
Excellent V. Good Good Fair Poor
Position in class/for Term I Term II Term III

(Attach a Report Form)
Student Discipline (Tick one option only)

Excellent V. Good Good Fair Poor
Head teacher’s brief comments on the student’s level of need, discipline and academic performance
__________________________________________________________________________________
__________________________________________________________________________________
Head Teacher’s Name ____________________________________ Signature _____________________
Mobile No. _____________________ Date ____________________ School Stamp _________________
FOR OFFICIAL USE ONLY

PART H: CHECK LIST FOR OFFICIAL USE DURING SUBMISSION AT THE NG-CDF OFFICE
STATUS
NO. ITEM DESCRIPTION (YES) (NO) (N/A)
1. NAMES DULLY FILED AND ADMISSION NUMBER
2. COPY OF STUDENT REPORT FORM
3. COPY OF ADMISSION LETTER FOR STUDENTS JOINING FORM 1
4. COPY/IES OF PARENT/S ID AND VOTERS CARD
5. FEE STATEMENT
6. COPY/IES OF DEATH CERTIFICATES FOR ORPHANS
7. EVIDENCE OF DISABILITY
Received By:
Name: ______________________________________ Designation: ________________________
Date: ________________________ Signature: ___________________________
PART I: FOR OFFICIAL USE BY NG-CDF BURSARY SUB COMMITTEE
Recommended ________________Not Recommended______________ Differed ________________

Justification____________________________________________________________________________
Amount Awarded ‘Kshs’__________________________________________________________________
Official’s Name____________________________________Designation____________________________
Signature________________________________________ Date______________________________

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Serial No.

NATIONAL GOVERNMENT CONSTITUENCIES DEVELOPMENT FUND

SECONDARY SCHOOLS BURSARY APPLICATION FORM

PART A: STUDENT’S PERSONAL DETAILS

FULL NAME _______________________ _________________________ ______________________

WARD_______________________ POLLING STATION ______________________________________

GENDER: MALE ( ) FEMALE ( ) DATE OF BIRTH ______________________________

PART B: SECONDARY SCHOOL PARTICULARS

Admission Number__________________ Form__________________ Year__________________

Page 1 Kasipul NG-CDF | Secondary Schools Bursary Application Form |

Address_____________________________________ Mobile No._____________________

PART C: BURSARY REQUEST

Amount Requested ‘Kshs’__________________ (Attach the Fee Statement)

Have you ever benefited from the Constituency Bursary Fund?

PART D: PARENT’S / GUARDIAN’S DETAILS

Total Orphans____________ Single Parent____________ Any Disability _____________

Name of Father_____________________________ Occupation______________________ Contact_______________

Name of Mother_____________________________ Occupation ______________________ Contact______________

Name of Guardian____________________________ Occupation ______________________Contact______________

Physical/ Postal /Permanent Address___________________________________________

Page 2 Kasipul NG-CDF | Secondary Schools Bursary Application Form |

Father Mother Guardian/Sponsor

2. APPLICANT’S SIBLINGS IN EDUCATIONAL INSTITUTIONS.

PART F: CERTIFICATION BY EITHER: CHIEF, ASSISTANT CHIEF OR RELIGIOUS LEADER

Name _______________________________ Signature __________________Date___________

Position/Designation_________________________________ Mobile No. _________________

(Official Stamp) ____________________________________

PART G: DECLARATION/ VERIFICATION

Student’s Signature……………………………………………... Date…………………..

Parent’s/Guardian’s Name ………………………….…………… Contact ……………………

Parent’s/Guardian’s Signature……………………………….…… Date………………………..

Page 3 Kasipul NG-CDF | Secondary Schools Bursary Application Form |

Position in class/for Term I Term II Term III

Student Discipline (Tick one option only)

Head Teacher’s Name ____________________________________ Signature _____________________

Mobile No. _____________________ Date ____________________ School Stamp _________________

FOR OFFICIAL USE ONLY

Name: ______________________________________ Designation: ________________________

Date: ________________________ Signature: ___________________________

PART I: FOR OFFICIAL USE BY NG-CDF BURSARY SUB COMMITTEE

Recommended ________________Not Recommended______________ Differed ________________

Page 4 Kasipul NG-CDF | Secondary Schools Bursary Application Form |

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FULL NAME ___________ _ __________

WARD_ POLLING STATION ________________

Admission Number Form Year__

Address_________________ Mobile No._

Total Orphans Single Parent Any Disability _

Name of Father_____________ Occupation Contact_

Name of Mother_____________ Occupation Contact

Name of Guardian____________ Occupation Contact

Name ___________________ Signature Date_

Position/Designation_________________ Mobile No. _

Head Teacher’s Name ________________ Signature _

Mobile No. _____ Date School Stamp _

Name: ______________ Designation:

Date: Signature: ___

Recommended Not Recommended Differed __