REPUBLIC OF KENYA
COUNTY GOVERNMENTOF WEST POKOT
P.O. Box 222-30600
KAPENGURIA
Email:
[email protected] www.westpokot.go.ke BURSARY APPLICATION 2022/2023
DEPARTMENT OF EDUCATION AND TECHNICAL TRAINING
INSTRUCTIONS: Fill the Application Form in legible CAPITAL letters. NB: Submission of incomplete form may lead to
disqualification. All duly filled forms should be delivered, on or before 30 th December, 2022, at the ward Office for onward
processing.
WEST POKOT COUNTY BURSARY APPLICATION FORM 2022/2023 FY
PART A: STUDENT CURRENT PHYSICAL ADDRESS
Sub county………………………………………………… Ward…………………………………………….
Location…………………………………….………… Name of the Chief: ……………………………..
Sub- location………….………………………………..Village………………………………………………..
PART B: STUDENT PERSONAL DETAILS (Fill where appropriate)
1. Full Name (Official Name) …………………………………........................................................................
2.Date of Birth………………………3.Gender …………… 4.Adm/Reg No.………………..……………….
5. Name of Institution (Attach copy of latest Report form)…………………………………………………….
6. County where the institution is located………………………………Sub-County…………………………
7. Tel. No. of (a) Applicant……………………………(b)Guardian/Parent…………………………………...
PART C: FAMILY INFORMATION (Attach copies of IDs)
1. (a) Name of father: ……………………………………(b) Name of mother: ………………………………
(c) Name of Guardian: ………………………………………………………….
(If deceased provide death certificate/ letter from local area Chief)
2. Occupation of parents (i) Father……………………………..……(ii) Mother ……………..…………………
3. Both parents alive: yes ……………. No ……….(if No attach death certificate or letter from local chief)
4. Single Parent. Yes …………………. No…………5. If you are an orphan, who provides for your school fees?
Self………....Guardian ……....………Sponsor…………………Any other (specify) ……………………………
6. Persons with disability Nature of disability:……………………………………………………………….
If registered with National Council of People with Disability, provide registration number………………………
6. Have you benefitted from ANY bursaries/Scholarships before? Yes………………NO………………………… (If
YES state the source and amount (a) CDF……………………………… (b) Ministry……..…………………..
(c) County Government ……………………………… (d) Any other………………….……………………………
PART D: APPLICANTS SIBLINGS IN EDUCATIONAL INSTITUTIONS
N Siblings Names Name of Institution Year of Total Fees Outstanding
o Study / Annual paid Fees
Form fees Arrears
1
2
3
4
5
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SCHOOL PERFORMANCE VERIFICATION
(Attach copy of latest Report form)
a). For Continuing Students Year of study……………………………………….
Performance: Term I ……….……. Term II ………….…Term III ..…………….
Students Discipline (tick one option only)
Excellent V. Good Good Fair Fair Poor
PART E: STUDENT DECLARATION
I…………………………………………………………………. herein, declare to the best of my knowledge that the
information given is true.
Signature ……………………….…… Date ………………..………
PART F: PARENT/GUARDIAN DECLARATION
I declare that I have read this form or it has been read to me and I hereby confirm that the information given hereunder is true
to the best of my knowledge.
Name ……………………………….……Signature ……………………… Date ……………………………
PART G: VERIFICATION BY AREA CHIEF / ASSISTANT CHIEF
Name of chief /Ass. Chief ……………………………………. …………………Sub-Location/ Location …………………..
Comments on the status of the family/ Parent .……………..…………………………….
…… ……………………………………………………………………………………………………………
I certify that the information given above is correct.
Signature …………………………… Date …………….……..…..Rubber stamp……………………….…
FOR OFFICIAL USE ONLY
WARD BURSARY APPRAISAL COMMITTEE/PANEL
Score: Qualified Not Qualified (Tick where Necessary)
Bursary awarded Kshs: …………………Bursary not awarded (Reasons)…………………………………….…
Chairperson …………………………..Signature ……………………….Date…………………………………..
Ward administrator (Secretary)………………………………Sign ………….………Stamp……………………
KEY ATTACHMENTS TO THE FORM
Applicants MUST attach copies of the relevant documents including the following:
1. Students' transcript/ Report Form
2. Photocopy of parents' / guardians National Identity Card
3. Photocopy of students' National Identity Card (Mandatory for post school students)
4. Photocopy of birth certificate
5. Photocopy of the secondary/ college / university ID card
6. Parents death certificate / burial permit/chiefs letter (mandatory for orphans)
7. Current fees structure (mandatory for all applicants)
8. Admission letters (mandatory for colleges and universities)
NOTE: “Successful applicants shall be notified”
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