MSU/RASA/F.

02C

MASENO UNIVERSITY
OFFICE OF THE REGISTRAR – ACADEMIC AND STUDENT AFFAIRS
Tel: 254-057351622, 351620,351008, Private Bag,
Fax: 254-057-351221 MASENO 40105
Mobile No.: 0722203411 Kenya
E-mail: [email protected] or [email protected]

STUDENTS PERSONAL DETAILS

Affix Passport Size
Photograph here

NAME________________________________________________________ ADM.NO.____________________
SURNAME OTHER NAMES

SCHOOL ADMITTED INTO_____________________________________________________________________

PROGRAMME ADMITTED FOR_________________________________________________________________

NOTE:
i. Complete 4 (four) of this form in Capital letters. Attach to each form a black and white passport
size photograph taken in one shot (NOT FROM A ‘PHOTO ME’ MACHINE).

ii. The names appearing in this form should be the same as those with which you were registered for
K.S.C.E./ official names on your other certificates.

iii. Information provided will be used for purposes of assisting the student whenever need arises. The
information therefore should be true and correct

1. Date of Birth____________________________/________________________/______________________
Day Month Year

2. Gender: Male Female (Tick whichever is appropriate)

3. Marital Status Married Single (Tick whichever is appropriate)

4. Name and address of spouse if married______________________________________________________

______________________________________________________________________________________

MASENO UNIVERSITY ISO 9001:2015 CERTIFIED

 MSU/RASA/F.02C

5. Place of Birth: Village______________ Location_____________________ County________________

Name of Chief_____________________________ ____________District __________________________

Nearest Police Station____________________________________________________________________

6. Nationality ___________________________Religion __________________________________________

7. Address for Correspondence

______________________________________________________________________________________

______________________________________________________________________________________

Telephone________________________ Fax _____________________ E-mail________________

8. Full Names of Mother____________________________________________________________________

9. Is mother alive or deceased? _______________________________________________________________

10. Full Names of Father ____________________________________________________________________

11. Is Father alive or deceased? _______________________________________________________________

12. Full names of Guardian (If neither 8 nor 10) __________________________________________________

13. Occupation of (a) Mother __________________________________________________________

(b) Father ___________________________________________________________

(c) Guardian ( is neither 13a nor 13b)

14. Names and Addresses of Brother(s) and Sisters(s)

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

MASENO UNIVERSITY ISO 9001:2015 CERTIFIED

 MSU/RASA/F.02C

15. Give Names, Addresses and Telephone Numbers of two people who can be contacted in case of
Emergency.
i. Name__________________________________ Relationship_________________________

Address________________________________ Telephone ___________________________

ii. Name __________________________________ Relationship_________________________

Address________________________________ Telephone ___________________________

16 Name and Address of last school attended.___________________________________________________

______________________________________________________________________________________

17. Index Number ____________________________________ Mean Grade__________________________

18. Subject Grade

_________________________________________________ ___________________________

_________________________________________________ ___________________________

_________________________________________________ ____________________________

_________________________________________________ ____________________________

_________________________________________________ ____________________________

________________________________________________ ____________________________

_________________________________________________ ____________________________

_________________________________________________ ____________________________

19. Do you suffer from any physical impairment? If so give details __________________________________

______________________________________________________________________________________

20. Please provide any further information that you think is useful to the university ______________

______________________________________________________________________________________

______________________________________________________________________________________

I certify that the information I have provided is correct:

Signature____________________________________ Date_________________________

Please make a Photocopy of this form and fill in quadruplicate (Fill in 4 copies)

MASENO UNIVERSITY ISO 9001:2015 CERTIFIED