KENYA INSTITUTE OF SOC IAL WORK AND C O M M U N I T Y DEVELOPMENT

Southern House 2nd Floor, Off Moi Avenue Opposite Meridian Hotel TEL NO. 0724772878 / 071384433/0733727406

BURSARYAPPLICATIONFORM
SECTION I: APPLICANT’S PERSONAL DETAILS

FULL NAME _

GENDER _AGE _MARITAL STATUS ID NO. _ _ (Attach copy of ID)

HOME DISTRICT _CONSTITUENCY

LOCATION _ _ _ SUB-LOCATION _ _

WARD/VILLAGE/ESTATE _ _

EMPLOYMENT DETAILS: _ _ _ __

HIGHEST LEVEL OF EDUCATION/TRAINING _ __

GRADE OBTAINED _ _ _

YEAR COMPLETED _ _ _ (Attach copy of Certificate/result slip)

PREVIOUS INSTITUTION/SCHOOL_ _ _ _ _

P. O. BOX _ _ _ POSTAL CODE _

ANY DISABILITY; (YES/NO) _ IF YES; MILD/SEVERE _ _ _

SPECIFY _ _

CURRENT MAILING ADDRERSS

P. O. BOX _ _ POSTAL CODE _ TEL _ _

SECTION II: FAMILY DETAILS

FATHER'S NAME ID NO: _ _ TEL _

OCCUPATION _ ANNUAL INCOME _ _

OTHER SOURCES OF INCOME _ _

IS FATHER ALIVE (YES/NO) _ _

MOTHER'S NAME_ _ _ ID NO: _ _ TEL _

OCCUPATION _ ANNUAL INCOME _

CURRENT MAILING ADDRERSS

P. O. BOX _ _ POSTAL CODE _ TEL _ _

OTHER SOURCES OF INCOME _ _

IS MOTHER ALIVE (YES/NO) _ _

GUARDIAN'S NAME_ _ ID NO: _ TEL

OCCUPATION _ ANNUAL INCOME _

CURRENT MAILING ADDRERSS

P. O. BOX _ _ POSTAL CODE _ TEL _ _

SECTION III: COURSE DETAILS

COURSE ADMITTED TO DURATION LEVEL _ _

FEES PAYABLE FOR WHOLE COURSE KHS _ _ _ _ _

AMOUNT APPLIED FOR IN KSH.__ _ _ _

DATE OF ADMISSION _ ADM NO. _ _

BRIEFLY EXPLAIN WHY YOU THINK YOU DESERVE THIS BURSARY

_ _ _
_ _ _
_ _ _ _
_ _ _ _

SECTION IV: APPLICANT'S DECLARATION

I confirm that the above information is true to the best of my knowledge and I am aware that giving false information will
lead to automatic disqualification.

_ _ _
NAME SIGNATURE DATE

SECTION: RECOMMENDATIONS

(a) Area Chief/Assistant Chief

I confirm/refute the information given by the applicant and I recommend/do not recommend the applicant for the award of
bursary.

_ _ _
NAME SIGNATURE DATE& OFFICIAL STAMP

(b) Religious Leader (Ordained Pastors, Bishop, Priest, Imam, etc)

I declare that the above information is true/not true to the best of my knowledge and I am aware that giving false
information will lead to automatic disqualification. I recommend/Do not recommend the applicant for bursary.

_ _ _
NAME SIGNATURE DATE & OFFICIAL STAMP

SECTION VI: INSTITUTIONAL COMMITTEE RECOMMENDATION

Following the Institutional Bursary Committee meeting held on (date) , the applicant's request for
bursary is hereby recommended/Not recommended as per minute number _
Bursary awarded Kshs _
If not recommended give reasons
_ _ _

Chairman _ Secretary _ _ _ _
Signature Signature

_ _ _ _
DATE AND OFFICIAL STAMP

KISWCD bursary application form 2