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REPUBLIC OF KENYA
COUNTY GOVERNMENT OF NYANDARUA
DEPARTMENT OF EDUCATION, CULTURE AND THE ARTS
P.O. Box 701- 20303, OL KALOU. Telephone: 0202660859. Email:
[email protected] BURSARY APPLICATION FORM
The Fund Administrator,
Thru’ the Ward Administrator ……………………………… Ward,
Nyandarua County Bursary Fund
PART A (STUDENTS PARTICULARS)
1. Full Name _______________________________________________________________
Last First Middle
2. Sex Male ( ) Female ( )
3. Sub County ………….……….. Ward …………………. Village……………………..
4. Date of Birth ……………………………. Students Contact: ……………….......
5. Name of School ___________________________________________________________
NEMIS NO._______________________ Admission No _____________Class/Form ______
6. Name of university or college_______________________________________________
Adm No__________________________ Year of study_______________________
*(For students joining Form one attach school admission form, final examination result slip,
and a leaving –certificate)
Name of the school Admitted __________________________________________________
Category of the school (tick the applicable category)
• National • Sub County
• Extra- County • Day school
• County
PART B AMOUNT APPLIED
• Total Payable Fees in words and figures-
In words_______________________________________________________________________
Figures (Kshs) __________________________________________________________________
• Outstanding Balance
In words ______________________________________________________________________
Figures (Kshs) __________________________________________________________________
• Amount paid or able to raise
In Words _____________________________________________________________________
Figures (Kshs) _________________________________________________________________
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• School Details (Mandatory)
Account Name _____________________________________________________________
Account No:_______________________________________________________________
Bank : ____________________________________________________________________
Branch: ___________________________________________________________________
Contact:______________________ E-mail:______________________________________
PART C: FAMILY INFORMATION
1 Tick appropriately
Family Status
Both parents are alive Single parent One parent is deceased
Orphan Both or one Parent/ Guardian has a disability
The student has a disability or a special education need
(Attach supporting documents e.g. death certificate, letter explaining disability or other
disadvantage/circumstances from chief, religious leader, prominent reference)
1. Parents/Guardian’s Name(s)
Father __________________________________________________
Occupation/Profession ____________________________________________________
Contact ________________________________________________________________
Age____________________________________________________________________
Mother _________________________________________________________________
Age____________________________________________________________________
Occupation/Profession ____________________________________________________
Contact ________________________________________________________________
Guardian
Occupation/Profession ____________________________________________________
Contact ________________________________________________________________
Age___________________________________________________________________
2. How many siblings do you have? _____________________
3. How many children does the guardian have? ____________
4. How many of your siblings are working/ in business/ farming? ___________
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5. Give details of your siblings/ guardian’s children in secondary or post-secondary
institutions in the table below;
Siblings’ Name/ Name of Institution Year of Total Fees Fees Paid Outstanding
Guardians Children Study Balance
GRAND TOTAL
6. If an orphan, who has been paying for your education? (State)
Name: ___________________________________________________________
Relation: _________________________________________________________
Contact: __________________________________________________________
PART D: INFORMATION ABOUT FAMILY FINANCIAL STATUS
GROSS INCOME IN THE LAST 12 MONTHS – (KSHS)
Father Mother Guardian/Sponsor
Main occupation
Other occupation
capable of raising
income
Gross income
➢ Gross income: (This means income from salary, business ,farming or any other
lawful source per year.)
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PART E: OTHER DISCLOSURES
DISCLOSURE OF ANY OTHER BURSARY BENEFIT
i. Have you received any other bursary or support from a public source? (Tick the relevant
box)
YES NO
If yes, disclose the source and the amount granted
Source __________________________________________________________________
Years received ____________________________________________________________
Amount granted ___________________________________________________________
ii. If you are a student in university or tertiary college, have you applied for financial support
from HELB? YES NO
iii. If YES, state the outcome and why you should be granted a bursary under this
programme: ____________________________________________________
iv. If No, state the reason __________________________________________________________
______________________________________________________________________________
1. STUDENT’S DECLARATION
I declare that to the best of my knowledge the information given herein is true
Student’s signature __________________________ Date ____________________
2. PARENTS/GUARDIAN’S DECLARATION
I declare that I have read this form/this form has been read to me and I hereby confirm that
the information given herein is true to the best of my knowledge.
Parent’s/Guardian’s Name: _____________________________________________________
Parent’s/guardian’s Signature ___________________________ Date ____________________
3. SCHOOL VERIFICATION
a) For Continuing Students (applicable to public secondary and boarding primary schools)
Year
Position in class/form Term I Term II Term III
Student’s Discipline (tick one option only)
Excellent V. Good Fair Poor
Principal/Head teacher’s brief comments on the student’s level of need, discipline and
academic performance.__________________________________________________________
Note: Applicant to Attach Latest Report Form.
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I confirm that the above is a continuing student in this school.
Principal/Head teacher’s Name _____________________________ Signature _____________
TSC No.____________
Date and School Stamp_______________________________________________________
AREA CHIEF/ASSISTANT CHIEF
Comment on the status of the family/parent
_________________________________________________________________________________
_________________________________________________________________________________
________________________________________________________________________
I certify that the information given above is correct.
Name: _______________________________ Signature: _______________ Date: __________
Position/Designation: _____________________________________________________
Date/ Stamp: _____________________________________________________
NOTEs
i. All relevant sections in this form MUST be filled and ensure that the information given is
correct.
ii. Wrong information will automatically disqualify the applicant.
iii. One should apply one form at a time and in one Ward ONLY.
iv. Supporting documents to be attached (compulsory).
a) Fees structures.
b) Admission letter.
c) Performance report/ Recent report form/ Transcript
d) School/ College/ University ID card.
e) Any other relevant documents.
PART E: FOR OFFICIAL USE ONLY BY THE WARD BURSARY ALLOCATION COMMITTEE.
TOTAL SCORE:
Approval (tick): Approved for Bursary Not approved for Bursary
Reasons for award or disapproval
_________________________________________________________________________________
_________________________________________________________________________________
Nature and terms of full or partial sponsorship
_________________________________________________________________________________
_________________________________________________________________________________
CHAIRMAN SECRETARY
Name: __________________________________ Name: _____________________________________
ID NO: _________________________________ PF/ ID NO: _________________________________
Signature: _______________________________ Signature: __________________________________
Date: ___________________________________ Date: ______________________________________
