National Government Constituencies Development Fund Wundanyi Constituency NG-CDF BUZLDING NEXT To HUDUMA CENTRE WUNDANYI TOWN P.O Box 1122-80304 'WUNDANYI Tel:0711919289 Email: [email protected] Website: www.wundanyingcdf.co.ke Grid Acro BURSARY APPLICATION FORM FOR STUDENTS IN SECONDARY SCHOOLS, COLLEGES AND UNIVERSITIES INSTRUCTIONS, 1. Kindly provide your information in legible CAPITAL LETTERS. 2, Have the form signed and stamped by the relevant ovthortes. 4. Attach a copy of your national identification card or parents/guardians 5. Copy of Student Report Card/ Transcrpt/ fees srcture} (where applicable) 6.For newly admitted students, attach a copy of the amissin letter to the institution of learning 7, For orphans attach a copy of death certificates or burial permits or « letter from the chief/assitort chief where applicable 8. For the disabled attach a copy of disabled Id card/Letter where epplicable 9. Attach « current duly cortifed report card/ transcript end the fee structure from the acaclemie institution. NOTE 1. The applicant MUST STRICTLY be «i resident of Wundanyi Constitueney and proof of this is 3. Any student who knowingly mokes folse statements/forgery (making of illegal rubber stamp! matter affecting the request of a bursary will be disqualified. 6. Approved bursaries will only he credited to institutions bank account and not to an individvel’s account, APPLICATION FORMS WITHOUT A COPY OF STUDENTS ADMISSION NUMBER/ REPORT CARD/ TRANSCRIPT WILL BE REJECTED This application is not © guarantee of a burtary awerd. Fully completed forms should be submitted on [ Jot the respective collection points for all Locetions/ Sub- locations . Kindly ensure your form is recorded on submission by counter-signing on the recard book. (No form will be accepted after the indicated date) APPLICANTS GENERAL DETAILS Location: SUB-LOCATION: POLLING STATION: ...sotstesssn PART A: TO BE FILLED BY THE APPLICANT / PARENT / GUARDIAN 1. PERSONAL & INSTITUTIONAL AND OTHER DETAILS FULL NAMES OF STUDENT (As it appears in your documents) Gender(tick where appropriate) Male [ ] Female { ] Date of birth__ National ID Number, (if applicable) Nome of School /Tertiary Institution/ College/ University Student Admission / Registration No. Campus/Branch (for Tetiory institutions & Universi) Faculty/ Department Tertiary isons & Universit) Mode of Study [Day School [ ] Boarding School { ] Regular { ] Parallel [ | Je#R. ational covennment CONSIITUENCIES DEVELOPMENT FUND WUNDANYI CONSTITUENCY PAGE 1 of 4ee | J} Other TI Form / Term /Aciclemic Year/ Semeste: | Courte Duration/Expected year af completic: [Mobile No; student /parent/guardian Physical Address / Permanent Address [institution Postal Address Institution Telephone Number ‘Amount awarded last Financial Year (Where applicable, please atlach the relevant supportive documents including the following ( Report Card, Transcript Fees Structure, Recommendation Letter, Letier of Admission for new Students) ae FAMILY BACKGROUND (Tick where applicable) indlly indicote your Family stotus Total Orphan Partial Orphan Single Parent Both parents Persons living with disability (tick where ‘oppropriate) Attach evidence Others (specify) ive Parent[ ] Student { J Number of Siblings (Alive) Estimated fami income ( Annually) Estimated family expenses ( Annually) (Attach photocopies of death certificate(s) and verification letters ram the erec Chiel/As:istant Chief where epplicable) @) Father's/Mother's Guardian Details: Full Nomes.. ephone No wees. Telephone Number. aes ID Number: Type of employment (Tick where applicable) Permanent{ ] Controctual { ] Cosval[ Retired { ] Self-employed( J Main Source of incom Polling Station ( Kitue Chake cha Kupig. Kuta)... b) Indicate the names of other siblings in other education institutions this year: iblings Name Name of the Year of | Tolalfee | Fee paid] Outstanding institution study/elass balance NATIONAL GOVERNMENT CONSTITUENCIES DEVELOPNENT FUND WUNDANT! CONSTITUENCY Page 2 of 4PARTB: EDUCATION FUNDING HISTORY 1.State the main source of funding for your education in the past (Fill where applicable} In Secondary Schoo! [ ]InCollege [ 1 In universtty [ 1 indicate other source of funding if arty Seconclary Schoo! [ } In College [ ]In university [ PART C: APPLICANTS ACADEMIC PERFOMANCE. ‘What Is your average academic performance. Excellent [ ] Very Good{ ] Good[ ]Fair{ ]Poorl ] Students Discipline (Tick where applicable). Excellent [_] Very Good[ ] Good { ]Fair{ ]Poor{ PARTD: _ INSTITUTION/SCHOOL RECOMMENDATION - STUDENT OR SCHOOL TO ATTACH LATEST FEES STRUCTURE REPORT CARD/ TRANSCRIPT (KWA UHAKIKISHO WA MWANAFUNZI ANAYEOMEA BLRSARY, INAFA MWANAFUNZI AMA MZAZI AMA SHULE KUAMBATISHA. (ATTACH) MUUNDO WA ADA / KAD] YA REPOT! YA HIV! KARIBUNI NA NAKALA (TRANSCRIPT FOR TERTIARY, ‘COLLEGES , UNIVERSITIES) Annual fees (as per fee structure ) Kshs [ 1 Last Term Fee Balance or Last Semester's balance [ ] This Term fees or Semester's Fees Ksh [ i Next term Fees or Semester's Fees Kshs [ } Loan from HELB (Where opplicoble) [ 1 Registered official Bank A/C Name to appear on Cheque. (Fill in block letters) Use school name as it appears on your Report card/Fees Structure/ Transcript) ACCOUNT NAME [ 1 ‘ACCOUNT NUMBER [ J NAME OF THE BANK/BRANCH [ 1 PART D: REFEREES The Student/Parent/ Guardian MUST provide the name and telephone contacts of at least two REFEREES who know the tomy wel TeNeme[ 1 Telephone 1 haaress [ 1 2.Name [ ] Telephone [ I Address [ PARTE: FOR STUDENTS WHO DO NOT HAVE SCHOOL FEE STRUCTURE/REPORT CARD/ TRANSCRIPT KINDLY VISIT YOUR RESPECTIVE INSTITUTION. ( Kwa wale wanafunzi ambeo hawana stakabadhi sinazohitajika tafadhali tembelea Shule/College/University kwa usaidizi zaidi,) I declare that the abeve named is a student in this school. Full Names..sseessees Designations. seumnnnsnn eeseeee Signature sees Contested lssusdecoresrsesa Emailessssseesseee Dote. Official Stamp. PART F: STUDENT'S, PARENT'S , GUARDIAN’S DECLARATION I hereby declare that the information provided herein is true to the best of my knowledge ond belief, ond | any false information provided shall lead to my cutomatic disqualification by the bursory committee, Applicants full names (Students) [ 1Signature [ 1 Date [ 1 [hereby declare that the information provided herein is true to the best of my knowledge and belief , and I any false information provided shall lead to my cutomatic disqualification by the bursary committee, Guardian's /Parent’s Full Name [ 1 Signature [ ] Date [ 1VERIFICATION: a) Area Chiof/Assitant Chief Comments | certify that the «ipplicant is @ resident of my Sub- Location/Location and | know the student family and acknowledge that the family needs assistance. Location [ 1 Sub location [ 1 Full Names [ ] Contacts [ ] Date [ ] Signature [ 1 Official stamp Recommended [ ] NotRecommended [ J ustification/or any other remarks? b) Religious Leader Full Names [ 1 Contacts { 1 Date [ ] Signature [ ] Official stamp Recommended [ ] NotRecommended [ ] Any remarks? BURSARY COMMITTEE ( FOR OFFICIAL USE ONLY ) Issuing Clerk Forms issued by [ JDote( / /2022) Signature [ 1 Place of issuance [ 1 NG-CDF Representative Sub- Location Name [ ]Date [ / /2022) Signature [ 1 ]Dere [ / 2022] Signature [ The form was duly filled & signed. Yes [ ]No[ |] All the supportive documents have been attached: Yes [ ]Ne{ ] Recommended for approval [ ] Not recommended for approval [ ] Reasons for non-approvel [ 1] Bursary Awarded ksh. [ ] Chairman [ ]Date{ / /2022) Signature [ 1 Secretary [ uote Lifer yaoeal Signature [ 1 BURSARY FORM VETTED BY: NO NAME SIGNATURE, DATE 1 2. 3 Je2&_wamowat covernnenr consTIUENcies DEVELOPMENT FUND WUNDANYI CONSTITUENCY PAGE 4 of 4