Serial No.
FY-
THE ANALO EDUCATION SUPPORT PROGRAMME
Patrick Analo Akivaga Sub locations: Tel No .+254 784 801 382
North Maragoli Kigama, Mudete,
Digula,Mulundu,Kiv
agala & Inyali
SECONDARY SCHOOLS BURSARY APPLICATION FORM
INSTRUCTIONS TO APPLICANTS
This application form is issued FREE OF CHARGE by Patrick Analo Akivaga.
1. Applicant must attach I.D. and voter’s card photocopies of parents /guardian.
2. Applicant must attach COPY of current report form.
3. Bursary awarded is not transferable by the beneficiary.
4. Approved bursary awards will be paid directly to the Institution and cannot be converted to cash payments to the applicant.
5. If single or both parents are dead, you must attach support document e.g. burial permit / death certificate.
6. Disability e.g. physically challenged: You must attach support document, letter explaining disability or other disadvantages
and circumstance.
7. The needs for all beneficiaries will be considered on application and canvassing is prohibited.
8. Cheating if detected, will lead to automatic disqualification.
9. All the information provided will be cross-checked against information from other official public sources.
10. You are required to fill in all appropriate spaces as provided.
11. Bursary application forms NOT dully filed will NOT be accepted.
12. Students joining FORM ONE MUST provide calling /admission letter and a Leaving School Certificate from the immediate
former Primary School signed and endorsed with an official stamp.
PART A: STUDENT’S PERSONAL DETAILS
FULL NAME
First Middle Last
LOCATION SUB LOCATION VILLAGE
GENDER: MALE ( ) FEMALE ( ) DATE OF BIRTH
PART B: SECONDARY SCHOOL PARTICULARS
Name of School
National County/Extra County Sub County Special
Admission Number Form Year
Postal Address
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For those students joining form I (Please attach joining calling/ admission letter)
Former Primary School Head Teacher’s Remarks
Student/Pupil Conduct Excellent V. Good Fair Poor
I declare that to the best of my knowledge the above information is true/or the applicant to attach a copy of
certified school leaving certificate.
Name Signature Date & School Stamp
Address Mobile No.
PART C: BURSARY REQUEST
Total Fee Payable per Year’ Kshs’ Amount Able To Raise’ Kshs’
Amount Requested ‘Kshs’ (Attach the Fee Statement)
Have you ever benefited from the Constituency Bursary Fund?
Yes No If Yes, state the amount Kshs.
PART D: PARENT’S / GUARDIAN’S DETAILS
Tick appropriately
Both Parents Alive Partial Orphans
Total Orphans Single Parent Any Disability
(If one or both parents are deceased, attach death certificate(s) and evidence of any disability)
Name of Father Occupation Contact
Name of Mother Occupation Contact
Name of Guardian Occupation Contact
Physical/ Postal /Permanent Address
Attach support documents: e.g (death certificates, letter explaining disability or other disadvantage
circumstance from Chief, Religious leader, prominent reference)
How many brothers and sisters do you have? How many children does the guardian have?
How many are in Secondary school? How many are in Post-Secondary Institutions?
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PART E: INFORMATION ABOUT FAMILY FINANCIAL STATUS.
1. GROSS INCOME IN THE LAST 12 MONTHS (KSHS.)
Father Mother Guardian/Sponsor
Gross Income
Gross income: (This means income from salary, business and farming)
2. APPLICANT’S SIBLINGS IN EDUCATIONAL INSTITUTIONS.
Siblings Name of Year of Outstanding
Name/Guardians Children Institution Study Class Total Fees Fees Paid Balance
Grand Total
PART F: CERTIFICATION BY EITHER: CHIEF, ASSISTANT CHIEF OR RELIGIOUS LEADER
Comment on the status of the family/parent
I certify that the information given above is correct.
Name Signature Date
Position/Designation Mobile No.
(Official Stamp)
PART G: DECLARATION/ VERIFICATION
1. STUDENT’S DECLARATION
I declare to the best of my knowledge that the information given herein is true.
Student’s Signature……………………………………………... Date…………………..
2. PARENT’S/GUARDIAN’S 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.
Parent’s/Guardian’s Name ………………………….…………… Contact ……………………
Parent’s/Guardian’s Signature……………………………….…… Date………………………..
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3. SCHOOL VERIFICATION
For ongoing students
Student Academic Performance (Tick one option only)
Excellent V. Good Good Fair Poor
Position in class/for Term I Term II Term III
(Attach a Report Form)
Student Discipline (Tick one option only)
Excellent V. Good Good Fair Poor
Head teacher’s brief comments on the student’s level of need, discipline and academic performance
Head Teacher’s Name Signature
Mobile No. Date School Stamp
FOR OFFICIAL USE ONLY
PART H: CHECK LIST FOR OFFICIAL USE DURING SUBMISSION AT THE NG-CDF OFFICE
STATUS
NO. ITEM DESCRIPTION (YES) (NO) (N/A)
1. NAMES DULLY FILED AND ADMISSION NUMBER
2. COPY OF STUDENT REPORT FORM
3. COPY OF ADMISSION LETTER FOR STUDENTS JOINING FORM 1
4. COPY/IES OF PARENT/S ID AND VOTERS CARD
5. FEE STATEMENT
6. COPY/IES OF DEATH CERTIFICATES FOR ORPHANS
7. EVIDENCE OF DISABILITY
Received By:
Name: Designation:
Date: Signature:
PART I: FOR OFFICIAL USE BY NG-CDF BURSARY SUB COMMITTEE
Recommended Not Recommended Differed
Justification
Amount Awarded ‘Kshs’
Official’s Name Designation
Signature Date
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