Private and Confidential

PERSONAL RECORD FORM

Instructions

1. Fill in all sections of the form legibly, either typed or in ink.

2. Ensure photocopies of certificates are enclosed as indicated in the form, and a photo is affixed above.
3. This document is important for our evaluation. It is in your interest to complete it to the best of your ability.

Page 1 of 7
 i.) Vacancy Applied for:

Vacancy/Post

vii.) Bio Data

Surname: Other names (in full) Gender : Male:___________

Female:__________

Postal Address: _____________________________ Telephone Contacts:______ ______________

Postal Code:_______________________________ Home:____________________________________

Town: ____________________________________ Business:________ __________________________________

Mobile:_________________________________

E-mail:______________________
Kenya Identity Card Number:
Temporary Address (if applicable)_____________________________
Passport Number and Country of Issue:
From:____________________ To:___________________

Nationality Date of Birth Age Country and place of birth

Kenyan
Other dependants:
Marital status:___ Number of Children:_______
Relationship
Age Age
Sex
Do you need a work permit for this job? Do you have a valid driving licence?

Have you ever been convicted of any criminal offences or a subject of probation order? If so please state the nature of the offence

Page 2 of 7
Have you ever been dismissed or otherwise removed from employment? If yes state reason(s) for dismissal/removal.

iii.) Next of Kin

Name: Age Relationship:

iv.) Health

Date and result of last medical examination:_________________________ Height:_______________

Weight:______________

Do you suffer from any physical impairment? Yes/No____________________ If Yes Please specify________________________________

Are there any industries or locations in which you are not able or willing to work? Please state.

v.) Availability

What period of notice do you require to serve your current employer?

vi.) Indicate the languages you are proficient in

Language Speaking Writing/Reading

Other(s) (Specify):Nandi

vii.) Academic/Professional qualifications – Starting with the highest (Please attach copies of education and professional certificates)

Institution Qualifications/Certificates Specialization/Sub Class/Grade Year

ject attained
From To

Other(s)

Page 3 of 7
viii.) Other relevant Courses and Training/Registration/membership to Professional Bodies/Institution

Year Institution/College Courses Details

(ix) Employment History starting with current or most recent employer

Employer’s Name Job title/ From To Key Responsibilities Basic Salary Reason for
Position held Month Month/ per month leaving
/Year Year
1.
2.
3.
4.
5.
6.
7.

(x.) Breaks in Employment: - Please indicate nature/reasons for any breaks in employment including relevant dates

Period
From To Nature/Reason

(xi) Present salary and benefits (please state denomination if not in Kenya shillings)

Basic Salary (Kshs.) Servants and Utilities

Tick the box if any the following are paid by your
employer

Page 4 of 7
House Benefit (Ksh.): House servant
Housing loan provided by the company: Gardener
Entitlement: Night Guard
Repayment period Water
Interest rate: Electricity
House allowance: (Ksh.) Telephone
If free housing provided, state market rental rate (Ksh.) Radio alarm
Other (Specify)
Car Benefit (Ksh.)
Car Loan provided by the company:
Entitlement: Educations
Outstanding: State whether your
children’s school fees is paid
Interest rate:
Are personal running expenses pair? If yes state amount per year Ksh.
(Ksh.)
Company car: Maximum number of
children paid for
Make: Entertainment allowance
CC: Amount per month Ksh.
Is it fully maintained?
Medical Benefit (Ksh.)
State maximum annual value of cover, and who in your family is Ksh per month
covered
Amount (Ksh. P.a) Members
covered
Outpatient:
Dental:
Optical:
Maternity:
In-patient
Others:
Pension scheme:
Is there a company scheme?
Employee contribution:
Employer contribution:
Provident fund:
Give details of your contribution to, and benefits provided, by any State type and estimated
provident fund value of any other benefits:
Benefit (specify) Amount (Ksh.)

Page 5 of 7
 Terminal gratuity: Annual leave (days)
Leisure interest Annual leave allowance

(xii) The information required below is important. Please take your time to complete it to the best of your ability

Please state how you would like your career to develop over the next five years. (CAREER OBJECTIVES)

What do you consider to be the main achievements of your career to date? (ACHIEVEMENTS)

Business interests other than main employment (specify general nature and your involvement) (INTERESTS)

xiv.) List three referees, including one from your previous employer
1st Referee – Current/Most recent Employer

Full Name:
Job title of referee:
Address:
Email:
Tel. Number:
Period for which he/she has known you:
In what capacity do you know this person?
May we approach him/her at this stage?
2nd Referee

Full Name:
Job title of referee:
Address:

Email:
Tel. Number:
Period for which he/she has known you:
In what capacity do you know this person?
May we approach him/her at this stage?

Page 6 of 7
3rd Referee

Full Name:
Job title of referee:
Address:
Email:
Tel. Number:
Period for which he/she has known you:
In what capacity do you know this person?
May we approach him/her at this stage?

Declaration Statement

I hereby certify that the information I have provided in this Personal Record Form, is to the best of my knowledge, correct,
true and complete in every aspect. I also understand that deliberately falsifying or withholding information may lead to
disqualification/legal action and dismissal if appointed.

Full Name:

Signature:
Date: (dd-mm-yyyy)

Page 7 of 7