SECONDARY SCHOOLS BURSARY APPLICATION FORM

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

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: cdfkasipul@ngcdf.go.ke

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_____________________________________________________________________

Serial No.

FY- 2019/2020

Page 2 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? _____

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

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/Guardians Children

Name of

Institution

Year of

Study Class

Total Fees

Fees Paid

Outstanding

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………………………..

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

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

NO.

ITEM DESCRIPTION

STATUS

(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______________________________