LEADERSHIP AND INTEGRITY ACT, 2012 /KIFUNGU CHA SHERIA CHA UONGOZI NA\ UADILIFU, 2012 FIRST SCHEDULE (S.13) / TARATIBU YA KWANZA 6.13) 1. GENERALINFORMATION / TAARIFA YA JUMLA Title /Cheo ‘Surname / Jina la | First Name /Jina | Middle Net Te homey ukoo Ja Kwanza Jina la ‘ee Marais Bd Mr/Mrs/Prof] Miss/Ms/Dr _ 3 Bw/Bi/Prof/ NQiG) TosePk | Kory Binti/Bibi/Dke 1D CARD Nio. PASSPORT NO._| EXPIRY DATE OF PASSPORT FINN. Na. ya Kitambulisho NA. ya PASIPOTI TAREHE YA MUDA WA NA. ya PIN PASIPOTI KUISHA. Wor as | Pe 00714929 ‘SEX (Tick) ‘Occupation: >= 5 2 JINSIA (Weka Alama) Kazi: QS Male ey E-Mail Address: | Kiume Anwani yo Baruapepe: Female Postal Address: PO Box 25S SM AWGoRode: Ro 217 Kike Anwani ya Posta: $l Posta: Msimbo: Other Adcresses: Anwani Nyingine: ‘Telephone No. ‘Mobile No. Other Numbers Na. ya Sima ‘Na. ya Runuru Nambarl Nyingine STIZZ HEARN? ESTATE/TOWN/IOCATION MTAA/MAW/LOKESHEN! NY dK 18 STRICT a WiLAYA Kinane? COUNTY RESIDENCE . pe Nanas a ane TOWN/EITY MU/L COUNTRY NCHI Ke wy ey 2. BIRTH INFORMATION / TAARIFA YA KUZALIWA DATE OF BIRTH /TAREHE YA KUZALIWA Wan Page a:BIRTH CERTIFICATE NO. / NA. YA CHETICHA KUZALIWA PLACE OF BIRTH / MANALI Pa KUZALIWA DISTRICT OF BIRTH / WILAVA VA KUZALIWA COUNTY OF BIRTH / KAUNTI YA KUZALIWA COUNTRY OF BIRTH NCH YA KUZALIWA 3. NATIONALITY /UTAIFA Kenyan [ Dual Mkenya Kotekote (Provide details, (Toa maelezo. ) 4. MARITAL STATUS / HALI YA NDOA SINGLE MARRIED. =] SEPARATED. NINGALI SUAOA/STTAOLEWA NIMEQA/NIMEOLEWA NIMETENGANA DIVORCED WIDOWED NIMETALAKIANA NIMEFIWA. IF MARRIED GIVE NAMES OF THE SPOUSE(S) (Surname, First Name, middle name, others) KAMA UMEOA TOA MAJINA YA MUME/MKE(Wo) WAKO (Jina la ukoo, Jina la Kwonza, jina la kati, ‘mengine) WHRoGsRs MARY GoRaeT NATIONALITY OF SPOUSE UTAIFA WA MKE/MUME Ke WY AW NAME OF CHILDREN UNDER THE AGE OF 18 YEARS JINA LA WATOTO WALIO CHINI YA UMRI WA MIAKA 18 Bulw Wace NyousR: FUNKE Wanitol 5. EDUCATIONAL QUALIFICATIONS / KUFUZU KWA KIELIMU PRIMARY CERTIFICATE -— SECONDARY [) LEVEL CHETI CHA MSINGI @— SHULEYA UPILI KIWANGO CHA ‘A’ DIPLOMA =[>] DEGREE [> MASTERS PHD STASHAHADA SHAHADA UZAMILI UZAMIFU OTHERS VINGINE Page 20f6HIGHEST ACADEMIC QUALIFICATION OBTAINED KUFUZU KWA JU ZAIDI KWA KIAKADEMIA ULIKOPATA Qualification / Kufuzu Institution / Taasisi Year /Mwaka Masters NMKO Qoai& 6, LANGUAGE SPOKEN / LUGHA UNAZOZUNGUMZA First Language Second Language Others Lugha ya Kwanza ugha ya Pili Nyingine Mikes yo ENGUstH Kis 7. MEMBERSHIP OF PROFESSIONAL ORGANISATION(s) (If any) UANACHAMA WA SHIRIKA(MA) YA KITAALAMU (Kama yapo) Name of Organization Date of Admission Memberthy Jina la Shirika Tarehe ya Kuandikishwo _| Na. ya U VS VAN TS 2SGNRC or 8. REASON(S) FOR DECLARATION / SABABU ZA KUJITANGAZA Purpose for which declaration is required / Kusudio la kuhitajika kwa kujitangaza huku Election Employment Upigaji kre LJ] kuajiria Others (Specify) PQeMeo Tion Nyingine (Bainisha) State office for which the declaration is being submitted Ofisi ya serikali ambayo kujitangaza huku kunawosilishwa 9. MORAL AND ETHICAL QUESTIONS / MASWALI YA NIDHAMU NA KIMAADILI ‘Answers to the following questions are mandatory. IF YES to any question you must provide additional information on a supplementary sheet. ‘Majibu kwa maswali yofuatayo ni lazima. Kama NDIYO katika swall lolote lazima utoe taarifa ya zioda kwenye karatasi nyingine. YES NO. a) Have you ever engaged in any form of dishonesty in the conduct of public affairs a) Umewahi kujjhusishe na hali yoyote ya kutokuwa mwaminifu katika | kazi zako na shughuli za umma 5 e ) Have you ever abused e public office? b) Umewahi kutumia vibaya ofisi ya umma? c) Have you ever misrepresented information to the public? 4) Have you ever engaged in wrongful conduct whilst in the furtherance of e ) Umewahi kuwakilisha kwo njia isiyofoataorifa kwa umma? ee Le personal benefit? Page 3 0f 6d) Umewahi kujihusisha katika tabia mbaya huku ukitaka kujinufaish kibinoysi?. e} Have you ever misused publicresources? e) Umewohi kutumia vibaye rosilimali za umma? \ f) Have you ever discriminated against anyone of any grounds other than as provided for under the Constitution or any other law? ‘) Umewahi kubagua yeyote kwa misingi yoyote mbali na vile ilivyoeleewa atika Katiba au sheria yoyote nyingine? 8) Have you ever falsified official or personal records? | g)Je, umewahi kudanganya katika rekodi rasmi au 2a kibinofs!? h) Have you ever been debarred or removed from the Register of Members of your professional organization? +h) Umewahi kupigwa teke au kuondolewa kutoko kwenye Rejista y Wanachama wa shirika loko la kitaclamu? |) Have you ever had any occupational or vocational license revoked\"\ and/or otherwise subjected to any other disciplinary action for cause. Kenya or any other country i)Umewahi kujigata katika hall ya leseni yako ya kikazi au yo kiufundi ‘utupiliwa mball no/au vinginevyo kuchukuliwa hatua nyingine ya inidhamu katika nchi ya Kenya au nchi yoyote nyingine |) Have you ever dismissed from employment on account of lack of integrity? j) Umewahi kufutwa kozi katika ajira kutokana no ukosefu wa vadillfu? k) If you have been a public officer, have you ever failed to declare your Income, Assets and Liabilities as required under the Public Officer Ethics Act, 2003? k) Kama umewahi kuwa ofisa wa umma, umewahi kushindwo kutangoza Mapato yako, Mali na Gharama kama unavyohitajika katika Kifungu cha sheria cha Maadill ya Ofisa wa Umma, 2003? |) Have you ever been the subject of disciplinary or criminal proceedings for breach of the Public Officer Ethics Act, 2003 or a Code prescribed thereunder? 1) Umewahi kuwa mado katika taratibu zo kinidhamu au kihalifu kwa ‘kuvunja kifungu cha sheria cha Maadili yo Ofisa wa Umma 2003, au Msimbo ulioainishwa hapo chini? im) Have you ever been convicted of any offence and sentenced to serve imprisonment for a period of at least,six months? m) Umewohi kushtakiwa kwa kosa olote na kuhukumiwa kifungo gerezani kwa kipindi kipatacho miezi sita? 'n) Have you ever had an application for a Certificate of Clearance ora Certificate of Good Conduct or for a visa or other document authorizing workin a public office denied and/or rejected for cause in Kenya or any other country? -. ae Woo Page 4 of 69) Umewohi kutuma ombi la Cheti cha kuondolewa Hatia au Cheti cha Kinidhamu au cha visa au nyaraka nyingine zinazoidhinisho kazi katika ofisi ya umma na hivyo basi wewe kunyimwa na/ au kukataliva kwa sababu yoyote nchini Kenya au nchi yoyote nyingine? 10. EMPLOYMENT INFORMATION / TAARIFA YA KUAJIRIWA NAME OF EMPLOYER POSITION/RANK DATE OF FIRST DATE OF PRESENT JINA LA MMWANIR CHEO/WADHIFA APPOINTMENT | APPOINTMENT TAREHE YA TAREHE YA KUAJIRIWA KWA | KUANIRIWA KWA KWANZA SASA Kae [SewroR Tenerea| jars Ro WORKSTATION NATURE OF EMPLOYMENT KITUO CHAKAZI (Constitutional/Elective/Permanent/Contractual AINA YA KUAJIRIWA (Kikatiba/Kuteuliwa/Kudumu/Kikandarasi/Nyingine) Race Peamawc Nt Page 50f6OATH AND AFFIRMATION / KIAPO NA UTHIBITISHWAJI anly swear (or affirm) and certify, under penalty of false declaration under_the Oaths and wry Declarations Act (Cap 15 of the Laws of Kenya), that all the foregoing statements in this, tion are true and correct to the best of my knowledge. \@ ya kwamba (ninathibitisha) na kuidhinisha, katika adhabu ya kujitangaza kwe uongo chin ingu cha sheria cha Viapo na Kyjitangaza Kisheria(Ibara 15 ya Sheria za Kenya), kwamba ote zilizotajwa katika kujitangaza huku ni za kweli na sahihi kwa Kadri ninavyojua. the} ene: DE. at / Mnamo tarehe... 1 sik ht ya SAR TURE OF DECLARANT: YA ANAYEJITANGAZA: BEM. ayo ttika mahali hapa. 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