REPUBLIC OF KENYA THARAKA CONSTITUENCY DEVELOPMENT FUND P.O BOX 33, MARIMANTIL. Our Reference: Date: YEAR: Constituency: District: Division: LOCATION = SUB/Location: WARD: | Villagertstate PART A : STUDENT PERSONAL DETAILS: Full Name LST NAME FIRST NAME MIDDLE NAME [Link]: CO mae (2) mae Date of birth ‘Admission No. Class [Link] of School Year: For those joining Form 1 (please attach joining instructions) (a)Schoot admitted [] National/[_] Provision/ [—] District (b) Formal primary school head teachers ‘Student/ pupil conduct: [—] Excellent/ [_] V. good/{_] Good fair/|__] Poor | declare that the best of my knowledge the above information is true of the applicant to attach ma copy of certified schoo! leaving certificate. NAME ‘SIGNATURE. DATE & SCHOOL STAMP For student either joining Form 1 or continuing in Form 2,3 or 4: Total Fees: Paid/Able to raise: ‘Outstanding balance: ‘Tharaka Constituency Development Fund 1 Bursary Application Form ww. tharakacdsorg[Link] INFORMATION Please tick appropriately. Both parents dead: ‘One parent dead (One parent dead: Both parents alive: Single parent Any disability: oO0000 (Attach support documents e.g Death Certificate, letter explaining disability or other disadvantaged circumstances either from Chief, religious leader or prominent referee) Father’s/Guardian’s Name: ‘Occupation/Profession Mother's/Guardian’s Name Occupation/Profession: [Link] many brothers and sisters do you have? 3. How many children does the guardian have? 4. How many are working/in business/farming? [Link] many are in sevondary institutions? ‘6, How many are in post-secondary institutions? 7 both parents are not alive, who has been paying for your education? Please tick: Guardian Sponsor or well wishers: [7] Any other (Specify) 8 Have you ever benefited from the constitueney’s bursary? Yes: (]_ No: [] 911f Yes above, please state the amount : Ksh. Tharaka Constituency Development Fund 2 Bursary Application Form www tharakacdf orEITHER CHIEF /SUB CHIEF ‘Comment on the status of the family parent: | certify that the information given above is correct, NAME: SIGNATURE: DATE: POSITION/DESIGNATION. OR:RELIGIOUS LEADER ‘Comment on the status of the family /parent: I certify thatthe information given above is correct: NAME SIGNATURE DATE (Oficial stamp) POSITION/DESIGNATION: PART C: INFORMATION ABOUT THE FAMILY FINANCIAL STATUS 1, GROSS INCOME FOR THE LAST 12 MONTHS: Father Mother Guardian/Sponsor | Well Wishers GROSS INCOME Gross income: This means from salary, business or farming Tharaka Constituency Development Fund 3 some tharukacds org Bursary Application FormAPPLICANTS SIBLINGS IN EDUCATIONAL INSTITUTIONS children ‘Sibling’s name/Guardian's | Name of Institution | Year of Study Total Fees Fees paid Ouistanding Balance GRAND TOTAL PART IECLARATION 1, STUDENT'S DECLARATION: I declare that to the best of my knowledge the information given here is true, 2, PARENT’S/GUARDIAN’S DECLARATION: Date: | declare that I have read this form/this form has been read to me and I hereby confirm that the information given here is true to the best of my knowledge. Parent’s/Guardian’s Name: Parent’s/Guardian’s Signature: SCHOOL VERIFICATION: a)For continuing students: Year: Position in class/form Term 1: Tharaka Constituency Development Fund 4 wwutharakacdf org Date: /Term 1: J Term Il: Bursary Application Form‘Students discipline (Tick one option only) Excellent (] ]_v.good(_] } Good (J } Fair] 1 Poor(] Headteacher’s brief comments on the student's Level need, discipline and academic performance: | declare that the above named student is in this school. Headteacher’s name: Signature: Date and School stamp: PART F: FOR OFFICIAL USE ONLY BY THE CONSTITUENCY BURSARY COMMITTEE SCORE: (2) Approved for bursary (C_ Not approved for bursary Reasons: Bursary awarded KSH ‘Chairman's Name: Signature: Date: Secretary's Name Signature: Date Official Stamp: Tharaka Constituency Development Fund 5 Bursary Application Form eww thorokocdf. org