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REPUBLIC OF ZAMBIA

CONSTITUENCY DEVELOPMENT FUND (CDF)

SECONDARY BOARDING SCHOOL BURSARY APPLICATION FORM

Complete all Sections in Capital/Block Letters

A. APPLICANT’S PERSONAL INFORMATION
Surname: First Name: Other Names: Sex F M
_____________________ _________________ __________________

Date of Birth: DD______ MM___________ YY______________ AGE:______

(Attach birth certificate where Possible)

Nationality: __________________________ NRC NO. (where applicable) _____________________

Province:______________District:______________________Constituency:_____________________

Ward: _______________________ Village/Township/Section: ____________________

Zone: ________________________

Type of vulnerability;_________________________________________________________________

Do you have a disability/special need? Yes, No

If yes, please Specify and attach relevant documentation

___________________________________________________________________________________

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 B. SCHOOL DETAILS (where you are enrolled or have been accepted)
(Attach a copy of an acceptance letter or confirmation letter from the school, this is a must)

Name of School where you are enrolled or have been accepted____________________________

School Location(District)___________________________(Province)________________________

Last School Attended_____________

Last Grade Attended_____________

Are you/ where you a boarder? Yes_____ No ______

Who has been paying your school fees________________________

Have you been supported by any organization? Yes _____ No _______

(if yes kindly give details) __________________________________________________________

C. DETAILS OF PARENTS /GUARDIANS

1. FATHER Alive Deceased

Attach documentation where applicable

Surname: First Name

Other Names:
Date of Birth: Telephone No:
Residential Address: Email Address:
Occupation:
Employer/Nature of Business:
NRC No:

Does father have a disability/special need? Yes, No

If yes, please specify and attach relevant documentation

___________________________________________________________________________________
_____________________________________________________________________________

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Does father have medical condition? Yes No

If yes, please specify and attach relevant documentation

___________________________________________________________________________________
_____________________________________________________________________________

2. MOTHER Alive Deceased

Attach documentation where applicable

Surname: First Name

Other Names:
Date of Birth: Telephone No:
Residential Address: Email Address:
Occupation:
Employer/Nature of Business:
NRC No:

Does mother have a disability/special need? Yes No

If yes, please specify and attach relevant documentation

___________________________________________________________________________________
_____________________________________________________________________________

Does mother have medical condition? Yes No

If yes, please specify and attach relevant documentation

___________________________________________________________________________________
_____________________________________________________________________________

3. GUARDIAN
Surname: First Name
Other Names: Gender:
Date of Birth: Telephone No:
Residential Address: Email Address:
Occupation:
Employer/Nature of Business:
NRC No: Relationship:

Does Guardian have a disability/special need? Yes No

If yes, please specify and attach relevant documentation

___________________________________________________________________________________
_____________________________________________________________________________

Does Guardian have medical condition? Yes No

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If yes, please specify and attach relevant
documentation______________________________________________________________________
___________________________________________________________________________________
_______
___________________________________________________________________________________
____________________________________________________________________________

D. INFORMATION ON SIBLINGS/DEPENDANTS TO PARENTS/GUARDIANS

(if siblings/dependents are in school, indicate who is supporting them)

Details of Siblings
No. Name Sex Age Occupation Alive/Deceased

Dependents to Parents/Guardians

No. Name Sex Age Occupation

E. FAMILY SOCIAL-ECONOMIC STATUS (Tick where applicable) – to be confirmed by

CWAC/CDA
i. House

Owned
Rented
Inherited
Sublet
Other (Specify)

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ii. Type of House Main Material of roof
Asbestos sheets
Asbestos Tiles
Other Non-asbestos tiles
Iron sheets
Grass/wood/thatch
Concrete

Main Material of floor

Earth/Sand
Wood planks
Palm/bamboo
Finished floor (wood tiles,
concrete, vinyl etc.)

Main material of wall

Natural walls (Mud, cane,
palm, trunks)
Rudimentary walls (stone or
bamboo with mud etc.)
Finished walls (bricks,
cement, wood planks, etc.)

iii. Toilet

Inside the house

Outside the house
iv. Water

Piped
Well
Shallow Well
Other (specify)
v. Source of water
Communal
Own premises

vi. Availability of Yes

electricity

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 No
vii. Main source of
income ...................................................................................................................................................

viii. No. of meals per day

One
Two
Three

Other (specify) …………………………………………….

ix. Does your

household have any
of the following
durable items?

Tractor
Plough
Hammer mill
Car/truck
Other (specify)
……………………
x. Does your
household own
poultry, livestock or
any other farm
animal? If yes, how
many

Cattle
Goats
Sheep
Pigs
Poultry
Other (Specify)

F. LIST OF ATTACHMENTS- (please tick what has been attached and /or indicate what is not
provided)
• Recommendation from previous sponsor (where applicable)

• Birth Certificate/s of applicant

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 • Death certificate/s of parents

• Pay slips/ proof of income of parents/guardian

• Medical record(s) of parent/guardian

• Disability card/ Confirmation of disability of applicant/parent/guardian

• Recommendation from traditional leadership

• Recommendation from Community Welfare Assistance Committee

• Acceptance letter /confirmation of enrollment

• Copy of application form

• Applicant to sign each and every page of this application document

Applicant (Learner) Contact person for Applicant

Name…………………………………… Name …………………………………………

Physical Address: ………………… Physical Address: ………………………..

……………………………………………….. …………………………………………………….

Phone (where applicable) Phone ……………………………………….

NRC……………………………………………..

……………………………… Signature…………………………………….

NRC (where applicable) Date…………………………………………….

………………………………………….

Signature…………………………………

Date………………………………………..

RECOMMENDED/ NOT RECOMMENDED BY THE WARD DEVELOPMENT COMMITTEE

Give Reasons
.........................................................................................................................................................
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.........................................................................................................................................................

Name:.............................................................................................................................................

Designation: ..................................................................................................................................

Signature:......................................................................................................................................

Date: ...............................................................................................................................................

APPROVED/NOT APPROVED BY THE CONSTITUENCY DEVELOPMENT FUND COMMITTEEE

Give Reasons
…………………………………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………..

Name: .............................................................................................................................................

Designation: .....................................................................................................................................

Signature: ........................................................................................................................................

Date: ................................................................................................................................................