EMCPSB FORM 12

ELGEYO MARAKWET COUNTY GOVERNMENT

COUNTY PUBLIC SERVICE BOARD

APPLICATION FOR EMPLOYMENT FORM

Elgeyo/Marakwet County Public Service Board Telephone +254 790570990

Email:[email protected] ke. PO BOX 665-30700
Website www.elgeyomarakwet.org/. ITEN.

1. Vacancy Applied For

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Vacancy/Post: …………………………………………………………………………......................................................Vacancy No:………………....

Department:…………........................…………………………….......................... Section:………………..……………………....................

Name: ……………………………….….....………..………….…..……..… ……………………………… ...... Title:……………………

(Surname) First Name Other Name(s): (Prof/Dr/Mr/Mrs/Miss/Ms/Rev)

Date of Birth.................................... ID No:……………………….. PIN.NO. ................................Gender: Male Female (dd-

mm-yyyy)

Nationality:……………………………….............. Ethnicity ................................................ County:………………………………….........

Sub County ........................... Ward :............................... Location……………………….sub-location………………….village…………………

Name of your Area chief……………………………………………………………………………………………………………………………………………………….

Postal Address:…………………………………………… Code:………………………………….. Town/City: ……………………….......................

Telephone No:……………………………………Mobile No:………………………………E-mail address:…………......…….…….……….............

Name of alternative contact person:……….………………..............................................................................

Phone No:……………………………........................
........

Are you a person living with a disability? Yes No

If yes, give;
(i) Details/Nature of Disability:………………………………………………………………………………………………...………………….........

(ii) Details of Registration with the National Council for People with Disabilities (Registration No. and
date)..................................................................

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3. Applicants in the Public Service ONLY

Ministry/State Department/ County/Other Public Institutions:……………..............................Station:…………………….…...........

Personal/Employment No:……………………….….….…… Present Substantive Post:……………………………………….........................................

Job group/Scale/Grade:………........................... Date of Current Appointment (dd-mm-yyyy).......……….........................................

Upgraded post (where applicable):……………………………………………effective date of previous appointment:…………………………….........

(dd-mm-yyyy)
On Secondment (where applicable): Organisation:......................................................
Designation:................................................Job Group/Grade:..........

Terms of Service: Permanent & Pensionable Contract Other, Please specify:.........................................................

4. All other Applicants

Current employer (where applicable):………………………………….............Position held:………....……..............……………...............................

Effective date: ……………….………….........................Gross Salary (monthly) Ksh.………………………………………………….........................

(dd-mm-yyyy)

5. Other Personal Details

Have you ever been convicted of any criminal offence or a subject of probation order? Yes No

If Yes, state nature of offence, the year and duration of conviction...................................................................................................

.......................................................................................................................................................................................................
.........................................

Have you ever been dismissed or otherwise removed from employment? Yes No

If Yes, State reason (s) for dismissal/removal…………………..……………………………………………………effective date………………

(dd-mm-yyyy)

(Declaring the above information will not necessarily debar an applicant from employment in the Public Service.
Each case will be considered on its own merit)

6 Academic Qualifications. (Starting with the Highest)

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 Award/Attainme
nt Specialization/Su
Course/Programme bject
University/ (e.g. Masters,
Year Bachelors, (e.g. PhD, MSc, BA, Class/Grade
High School (e. g Econ, Maths,
Degree, O’Level)
Sociology e.t.c)
KCSE)
From To

7 Professional/Technical Qualifications/Certifications Relevant to the post. (Starting with the Highest)

ademic /Professional/Technical Qualifications Relevant to the post. (Starting with the Highest)
Year Specialization/Subje
ct
Award/Attainment (e. g Human
(e.g. Higher Diploma, Resource,
Institution Class/ Grade
Diploma, Engineering,
From To Certificate) Counselling
e.t.c)

8 Relevant Courses and Training attended Lasting not Less than One (1) Week

Year University/College/Institution Name of Course Details and duration

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 …
11. Briefly state your current duties, responsibilities and assignments (if any)
…

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12. Please give details of your abilities, skills and experience which you consider relevant to the position applied for. This .
information may include an outline of your most recent achievements and your reasons for applying for this post.

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 13. Referees (people who have inter

1. Full Name:……………………………………………………………………………..………………………………………………………………...
Occupation:…………………………………………………………………………………...…………………………………………………………….

Address:………………………………………………………Post Code:………………………………...City/Town: …………....................................

Mobile No:…………………………………………………………… E-mail address:……………………………………………………….................

Period for which the referee has known you:………………………………………..……………………………………………………........................

2. Full Name:……………………………………………………………………………….……………….……………………………………………...
Occupation:………………………………………………………………………………………………..…………………………….………………….

Address:……………………………………………............ Post Code:……………………………….......City/Town: ………………………………....

Mobile No:……………………………………………....................... E-mail address:……………………………………………………......................

Period for which the referee has known you:……………………………………………………………….…………………………………….……......

13.Declaration
I ……………………………certify that the particulars given on this form are correct and understand that any incorrect /misleading
information may lead to disqualification and/or legal action.

Date: ……………………………. Signature …………………………….. u profess

dd/mm/yyyy signature of applicant
sionally)

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