TCG Application Form Soft

COUNTY GOVERNMENT OF TURKANA
MINISTRY OF EDUCATION, SPORTS AND SOCIAL

PROTECTION
WARD BURSARY APPLICATION FORM [Section 10]
A. STUDENTS PERSONAL DETAILS

1. Full Name: …………………………………………………………………………………
2. Sub County: ………………………………………………Ward: ………………………...
3. Village unit: ………………………………………………
4. Date of birth: ……………………………………………..
5. Sex: Male: Female:
6. Name of the Institution:
(a) Secondary: Name: …………………………………………………………………….
Form: ………………………….
(b) Post –Secondary(i) College/TVET: Name: ……………………………………………
Year: …………………………
(ii) University: Name: ………………………………………………………………….
Year: …………………………
7. Admission Number: …………………………………………….
B. AMOUNTS APPLIED
8. (a) (i) Total payable fee: in words and figures
………...................…………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
1
(ii) Outstanding balance: in words and figures
…………...…………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
(iii) Amount paid/able to pay: in words and figures
………………………………………………………………………………………..……
………………………………………………………………………………………………
………………………………………………………………………………………………
(b) School/College/University bank details
Account Name: …………………………………………………
Account Number: ………………………………………………
Bank Name: …………………………………………….… Branch: ……………..……….
C. FAMILY DETAILS (Tick where appropriate)

9. Family status:
Both parents alive Single parent Orphan
One parent deceased Both parents/guardian has a disability
10. The student has a disability or special education need? Yes No
11. Parents/guardian name(s)
…………………………………………………………………………………………….
Occupation: ………………………………………………. Contact: ……………………
12. How many siblings do you have?

…………………………………………………………..
13. How many children does the guardian have?
…………………………………………………………………………………..…………
14. How many of your siblings are working/in business/farming?
………………………………………………………………………………………………
2
15. (a) How many of your siblings /Guardian children are in secondary
school/colleges/university? (Give details)
Siblings/Guardian Name of Year/Class Total Fee Outstanding
children’s Name Institution fees paid balance
(c) If orphan, who has been paying for your education?
Name:………………………………………… Relation: ………………………………….
Contact: ……………………………………………………………………
D. INFORMATION ABOUT FAMILY FINANCIAL STATUS

16. Gross income in the last 12 months in KSH.
Father Mother Guardian/Sponsor
Main occupation
Gross income in
KSH.
NB: Gross income means income from salary, business, farming or any other lawful source of
income per year
3
E. OTHER DISCLOSURES
17. (a) Have you received any other bursary or support from a public source in the last three
months? Yes No
(b) If yes state the source and the amount in KShs

………………………………………………………………………………………………
………………………………………………………………………………………………
(c) If you are a student of the university or tertiary college, have you applied for financial
support from HELB?
………………………………………………………………………………………………
………………………………………………………………………………………………
18. If yes in 17(b) above state, the outcome and why you should be granted a bursary under
this program
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
If no in 17(c) above state reasons
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
F: DECLARATIONS
19. Students Declaration:
I declare that to the best of my knowledge the information given herein is true and to the best of
knowledge
Student’s signature:……………………………………..Date: ...................................……………
4
20. Parents/Guardians 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.
Parents/Guardian Name:
………………………………………………………………………………....................
Parents/Guardian signature:
…………………………………………………………………………………………………….
Date: ………………………………………………………………………………………………
21. School/College/University Verification

(a) For continuing students only
Year ………………………………. Position in class: Term I
Term II ……………………………. Term III ………………………………………….
Student’s discipline: Excellent ………………………………. Good ………………
Fair ………………………… Poor ………………………………………………………………
Principal brief comments on the student’s level of need, discipline and academic performance
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
I declare the above is a student in my school
Principal’s Name: ……………………………………………………………………………
Signature: ……………………………………………………………………………………..
Date and school Stamp: ………………………………………………………………..
(b) College students can attach recent transcripts or a letter from the college/university on his
performance
5
G. OTHER ACKNOWLEGEMENTS
Area Village Administrator or Religious Leader.
Comments on the status of the family/parent
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
I certify the applicant’s information given is correct/not correct
Name: …………………………………Signature: ………………………….
Date: ……………………………………………………………………
Designation: …………………………………………………………
Official Stamp: …………………………………
H. OFFICAL USE ONLY BY WARD BURSARY COMMITTEE

Total Score
Approved for bursary Not approved for bursary
Reasons for approval or disapproval
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
Notes:
i. Attach supporting documents e.g Death Certificate, NCPWD card or a letter
ii. Applicant to attach the latest report form for secondary school students and any
other similar supporting for tertiary education students
iii. Wrong information will automatically disqualify the applicant
iv. Supporting documents to be attached:
(a) Fees structure
(b) Admission letter where necessary
(c) Performance report/transcript
(d) Copy of School/College ID
(e) NCPWD card where necessary
(f) Death certificate where necessary
(g) Any other necessary supporting documents.

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COUNTY GOVERNMENT OF TURKANA

MINISTRY OF EDUCATION, SPORTS AND SOCIAL

A. STUDENTS PERSONAL DETAILS

C. FAMILY DETAILS (Tick where appropriate)

Occupation: ………………………………………………. Contact: ……………………

12. How many siblings do you have?

14. How many of your siblings are working/in business/farming?

(c) If orphan, who has been paying for your education?

Name:………………………………………… Relation: ………………………………….

D. INFORMATION ABOUT FAMILY FINANCIAL STATUS

(b) If yes state the source and the amount in KShs

If no in 17(c) above state reasons

19. Students Declaration:

Student’s signature:……………………………………..Date: ...................................……………

21. School/College/University Verification

Year ………………………………. Position in class: Term I

Term II ……………………………. Term III ………………………………………….

Student’s discipline: Excellent ………………………………. Good ………………

Fair ………………………… Poor ………………………………………………………………

I declare the above is a student in my school

Principal’s Name: ……………………………………………………………………………

Date and school Stamp: ………………………………………………………………..

H. OFFICAL USE ONLY BY WARD BURSARY COMMITTEE

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