PERSONAL HISTORY FORM
KIPPRA/QMS/HR/2023/05
1. Personal Details
Name in Full: ………………………………………………………...…………………………………………………………..
Date of Birth: …………………………………….. Marital Status: …………………….……………………..
Nationality: ……………………………………….. ID Number ………………………………………………..
For Candidates Living with Disability.
NCPWD Reg No…………………………………………………………………………..……………………………………
2. Contact Details
Permanent Address: …………………………… Postal Code: ………………..………………………..….
Home Tel: …………………………………………. Mobile: ……………………..……………………………..
Office Tel: …………………………….…………… E-mail ………………...……………………………………
County of Residence: ……………………………………………………………………………………………………
3. (a) Education
Year College/University Degree/Diploma/Certificate Main Course of
Awarded Study
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(b) Professional Courses attended:
i) ____________________________________________________________________
ii) ____________________________________________________________________
iii) ____________________________________________________________________
iv) ____________________________________________________________________
v) ____________________________________________________________________
(c) Membership of professional Bodies.
i) ____________________________________________________________________
ii) ____________________________________________________________________
iii) ____________________________________________________________________
4. Employment Record
Year Name and Address Position Monthly Reason (s) for
of Employer Held/Description of Gross Leaving
Duties Salary
5. Computer Knowledge/Skills (Excellent, Good, Fair, Poor)
Computer Software Proficiency
Word
Excel
PowerPoint
Access
E-Views
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Stata
Rats
GAMS
ArchGIS
SPSS
PageMaker
InDesign
QuarkXpress
Illustrator
Photoshop
Internet/E-mail
Others:
6. Language Proficiency (Good, Fair, Poor)
Language Write Speak Read
7. Previous Work/Publications (List any significant publications).
Year Publication/previous assignments Year
8. Personal References (Provide details of three professional references)
Full Name Postal Address, Tel. No. & Occupation
E-mail address
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9. Other Important Information
Please provide any other information to support your application. Also, indicate your
reasons/interests to work for KIPPRA. You can use a separate sheet.
10. CV, Certificates and Testimonials
Please attach a detailed and updated signed copy of CV and copies of academic
certificates and testimonials.
11. DECLARATION
I certify that the information provided above is true, complete, and correct to the best of
my knowledge and belief. Any misrepresentation or material omission made on a
Personal History Form or other document requested by KIPPRA renders the applicant to
disqualification.
Signed ___________________________________ Date ___________________________
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(Optional) Candidate Voluntary Self-Identification
KIPPRA believes that all persons are entitled to equal employment opportunities and
we do not discriminate against our employees, applicants or job seekers because of
race, ethnicity, gender, religion, national origin, disability or any other protected group
status as defined by the laws.
Please complete the information below which includes the option to choose not to self-
Identify. Refusal to provide this information will not affect consideration of your
application.
This information will be kept confidential.
I do not wish to complete the information requested below.
Gender
What is your gender?
Female
Male
Prefer not to say
Disability
The following information is collected for purposes of monitoring our policies. It will
therefore be used for statistical, monitoring and compliance purposes and will be held
in confidence.
Do you regard
Yes
yourself as in any
No
way disabled?
Prefer not to say
If yes, what is the
Please tick the appropriate box. If you experience more than one type of
nature of your
impairment, please tick the box next to all of the types that apply. If your disability
disability?
does not fit any of these types, please tick other.
Specific learning disability (such as dyslexia or dyspraxia)
General learning disability (such as Down’s Syndrome)
Cognitive impairment (such as autistic spectrum disorder or resulting from
head injury)
Long-standing illness or health condition (such as cancer, HIV, diabetes,
chronic heart disease, or epilepsy
Mental health condition (such as depression or schizophrenia)
Physical impairment or mobility issues (such as difficulty using arms or using
a wheelchair or crutches)
Deaf or serious hearing impairment
Blind or serious visual impairment
Other type of disability
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