CONFIDENTIAL FORM: HN001

Digital
DATE photo
DD MM YY Y Y
Serial Number: DIGITAL DATA CAPTURE FORM
(If a child's Age < 6yrs fill the Bio Data Information, Birth Certificate /Notification Entry No, Parent's Details and Exit!)
Bio Data Information
First Name Middle Name Surname Other Names
Name:

Gender: Date of Birth:

( ) Male ( ) Female
Section 1

D D MM YYYY
Place of Birth Details
Country: County: Sub-County: Division: Location: Sub-Location:

Disability
Are you living with disability? If yes, specify: Disability Registration Number
( ) Yes ( ) No I I I I I I I I
Citizenship Information
Citizen Non- Citizen
ID/NO. O. Nationality: Country of Origin:

I I I I I I I I I I I I I I I I
Passport NO. Alien ID. No./Refugee NO.
NHIF NO. Driver’s Licence NO.
I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
NSSF NO. KRA PIN NO.
I I I I I I I I I I I I I I I I
(Expiry date)
DD MM YYYY
(Expiry date)
D D MM Y Y Y Y

Status:
Passport NO. I I I I I I I I I ( ) Work Permit ( ) Special Pass ( ) Dependant Pass
Section 2

( ) Pupil Pass ( ) Intern ( ) Refugee

(Expiry date)
DD MM Y YYY ( ) Asylum ( ) Stateless ( ) Other
Marital Status Spouse Details ID/Passport No.
( ) Single Spouse Name First Name Middle Name Surname

( ) Married 1. I I I I I I I I
( ) Separated 2. I I I I I I I I
( ) Divorced 3. I I I I I I I I
( ) Widowed 4. I I I I I I I I
5.
I I I I I I I I
Parents/Guardian Details
Father’s First Name Middle Name Surname ( ) Deceased

I I I I I I I I
ID/No. /
Name : Passport No.
( ) Alive

Mother’s First Name Middle Name Surname ( ) Deceased

I I I I I I I I
ID/No. /
Name: Passport No.
( ) Alive

Guardian First Name Middle Name Surname ( ) Deceased

I I I I I I I I
ID/No. /
Individual Passport No.
( ) Alive
Name:
Guardian Institution Name
Name: Registration No. I I I I I I I I I
Huduma Namba Registration is mandatory as per Section 9A of the Registration of Persons Act (Cap.107). It will enable the Government to provide you with services. This form
and the registration process is absolutely free of charge.
 Permanent Physical Address/Home Address
County: Sub-County: Division:

Location: Sub-Location: Village/Estate/House No.

Section 3

Current Physical Address

County: Sub-County: Division:
Location: Sub-Location: Village/Estate/House No.
Contact Details
Postal Address: Postal Code: Primary Phone Number Email Address:

I I I I I I I I
Education Details
Level of Education (tick the highest level) If currently studying, which level? NEMIS No:
( ) Pre-primary ( ) Pre-primary
( ) Primary ( ) Primary
Section 4

( ) Secondary ( ) Secondary
( ) Vocational
( ) Middle level colleges
( ) Vocational
( ) Middle level colleges
I I I I I I I I I
( ) Undergraduate ( ) Undergraduate
( ) Postgraduate ( ) Postgraduate
Other:__________________________________________ Other:_________________________
Employment Status
Type of Industry: If Self-Employed:
( ) Employed ( ) Self-Employed ( ) Unemployed ( )Large ( ) Medium
( ) Service ( ) Industrial ( ) Agricultural ( ) Small & Micro (SME)
( ) Retired ( ) Casual
Agricultural Activities
Are you engaged in agricultural activities? What is the Land tenure/Ownership What is the size of the farm?
( ) Yes ( ) No status?
Section 5

.............................................................................................................................. ( ) below 5 acres ( ) 10-50 acres

If yes specify: ( ) Fish Farming ( ) Tree Farming
( ) Leased ( ) Community
( ) Crops ( ) Livestock ( ) 5-10 acres ( ) 50-100 acres
Do you practice irrigation? ( ) Private ( ) Public Land
( )over 100 acres
( ) Yes ( ) No

Biometric Details
Digital Fingerprints:
Section 6

Right Index Right Ring

Right Thumb

Right Little
Right Middle

Respondent: ( ) Self ( ) Parent ( ) Other

..............................................................................................................................
If other
ID/No./ Passport No.
Section 7

First Name Middle Name Surname

I I I I I I I I I
Disclaimer: a
systems. I understand that my information may be provided to an authorised Government agency/agencies.
Agree
Digital Respondent’s
Signature
Name
or First Name Middle Name Surname Signature, Stamp and
Digital Respondent’s
Left Thumb Print Fingerprint:

Remarks:

Should the space provided on this form be insufficient, fill the additional information on a white A4 sheet of paper and attach to this form. Write the Registration
Number of this form at the top of any additional sheets.
2