COMMUNITY EDUCATION SERVICES- KENYA

SCHOLARSHIP APPLICATION FORM (REVISED 2010)

 

YEAR___________________________     DIVISION____________________

 

DISTRICT _______________________       SUB-LOCATION______________

 

LOCATION _____________________

PART “A” STUDENTS PERSONAL PARTICULARS

FULL NAMES:

Last                                                First                                 Middle

 

_______________           ____________       __________

SEX: MALE            (         )                                   FEMALE              (          )

Date of Birth _______________ Admission No______________ Class ______

 

For those joining form one : KCPE Marks   ______________________________

 

School admitted :            National                    Provincial                   District

 

Class position: Term I………………… Term II ………………. Term III …………

 

FEE DETAILS:

a) Total fees                  Kshs_____________________________

b) Paid/able                   Kshs_____________________________

c) Outstanding/balance            Ksh.________________________

 

FAMILY INFORMATION

I.     Is your father Alive                           Yes                           No

II.     Is your mother alive                          Yes                           No

III.     Any other information …………………………………………

(If not alive attach copies of death certificates or report from the Assistant Chief)

IV.     Father name………………………….. occupation /Profession ………………..

V.     Mother’s name ……………………..   occupation/Profession ………………..

VI.     Guardians name ……………………   occupation/Profession ……………….

VII.     How many brothers and sisters do you have?

VIII.     How many are working in business

IX.     How many  are in secondary school

X.     How many are in post secondary institutions

Who pays for your education?

Parent/Guardian                        Sponsor

PART B: INFORMATION ABOUT OTHER FAMILY FINANCIAL OBLIGATIONS

 

SIBLINGS NAME	NAME OF INSTITUTION	YEAR OF STUDY	TOTAL FEES	FEES PAID	BALANCE OUTSTANDING

DECLARATION BY STUDENT: I declare that the information given herein is true to the best of my knowledge.

 

Students signature : ……………………………………………………………….

Date : ……………………………………

DECLARATION BY PARENT/GUARDIAN: I declare that I have read this form/this form has been read to me and I hereby declare that the information given herein is true to the best of my knowledge.

 

Parents signature_______________________________________________________

 

Date: _______________________________________________________________

 

PART “C” CERTIFICATION

a)     To be completed by Chief/Assistant Chief/Religious leaders

I certify that the above named students hails from my area of jurisdiction

 

Signature_______________________ Date: _________________________

 

Official ________________________

 

b)    To  be completed by Secondary School teacher

Student/pupil conduct

Excellent                       V. Good                Good                  Fair                 Poor

I certify that the above named is a student in this school

 

Headteacher’s Name                                    Signature

 

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

Date and School Rubber stamp

 

 

………………………………………………………………………………………

PART D: RECOMMENDATION BY SCHOOL SELECTION COMMITTEE

 

We the undersigned have interviewed the candidate named on this form and based on the information provided on the form we are satisfied that he/she meets the criteria for financial support.

 

PRINCIPAL (Chairman)                                     Signed   ……………………………

 

Senior Master (D/Chairman)                            Signed ……………………………..

 

Guiding/Counseling Master- member          Signed ……………………………..

 

Class teacher             (Secretary)                         Signed …………………………….

 

PART “E” FOR OFFICIAL USE

 

Approved……………………………………………………………………………………

 

Chairman, Ces Kenya

 

 

Date …………………………………………………