SERIAL NO: …………………………………

BOMACHOGE BORABU CONSTITUENCY

BURSARY APPLICATION FORM (FY 2022/2023)

(TERTIARY INSTITUTIONS)

1. IDENTIFICATION
Name in Full (Block letters): _______________________________________________________
Gender: ______________ Date of Birth: ____________________ Id.No.:

Ward: ___________________ Location: _________________ Sub – Location: _____________

Village: _____________________
Address: _______________ Tel: _____________________
Email: ________________________________________

Institution: __________________________________
Branch/Campus: County:
Course: _________________________ Admission No: __________________________
Year of Study: Mode of Study:

Employed: Yes: No: Business: Yes: No:

2. FEES REQUIREMENT
a) Year Fees : Kshs. ________________________________________
b) How much are you requesting from NG-CDF: Kshs. _____________________________________
c) How much are you able to raise: Kshs. _______________________________________________
d) How much bursary have you or any of your siblings received from NG-CDF: _________________
e) Are your parents/guardian/sponsor employed or in business? Yes: No:
f) Do you have any other bursary/Scholarship? Yes: ________________ No: __________________

Bomachoge Borabu NGCDF (FY 2022/2023) Page 1

 3. FAMILY STATUS
a) Total orphan ___________________________
b) Partial orphan ____________________________
c) Single Parent ____________________________
d) Disabled Parent(s) ____________________________
e) All Parents Present _____________________________
f) Number of Siblings

4. PARENTS’ / GUARDIAN OCCUPATION AND INCOME

PARENT NAME OCCUPATION ADDDRESS TEL HOUSEHOLD
INCOME/YEAR
FATHER

MOTHER
GUARDIAN/
SIBLING(S)
TOTAL HOUSEHOLD
INCOME

5. INSTITUTION DETAILS
(To Be filled by Head of institution / Bursar / Finance Officer)

Name of the Instituion / Campus_______________________________

Campus/Branch: _______________

Address: _____________________ Tel: ____________________

Bank: ___________________________________________ Branch: ___________________

Account Number: __________________________________________________

Name of Head of Instituion / Bursar / Finance Officer: __________________________________

Signature: ____________________________________ Date / Stamp: ___________________

Bomachoge Borabu NGCDF (FY 2022/2023) Page 2

 6. (a) DECLARATION
STUDENT

I ……………………………………………………………………………………….... (NAME) of Tel.No.: …………………………………..…

hereby declare that the information given herein is true to the best of my knowledge.

Signature: ……………………………………………………………… Id.No.: ………………………………… Date: ………………………..

PARENT/GUARDIAN OF APPLICANT

I ……………………………………………………………………………………….... (NAME) being the ………………………………………

(relationship) of the above applicant hereby declare that the information given herein is true to the best
of my knowledge.

Signature: ……………………………………………………………… Id.No.: ………………………………… Date: ………………………..

(b) CERTIFICATION (Either)

I/We confirm the information as provided herein is true to the best of my/our knowledge;

Pastor/Priest/Imam ____________________________________

Signature ____________________________________

Date / Stamp ____________________________________

Assistant Chief ____________________________________

Sinature ____________________________________

Date / Stamp ____________________________________

Chief ____________________________________

Signature ____________________________________

Date / Stamp ____________________________________

Bomachoge Borabu NGCDF (FY 2022/2023) Page 3

FOR OFFICIAL USE ONLY
Bursary Sub-Committee

Recommendation ___________________________ Not recommended ___________________________

Deffered _______________________________________________________________

Reasons for deferring / Non recommendation

Chairman _____________________________ Signed __________________________Date___________

NG - Constituency Development Fund Committee

Approved _______________________ Not approved_________________ Deferred _________________

Bursary Awarded Kshs ________________________________

Reasons for Disapproval ________________________________

NG-CDF Chairman __________________ Date

NG-CDF Secretary ____________________________________ Date ______________________

Fund Account Manager ________________ Date _____________

Note

 Any false information, canvassing / soliciting will lead to disqualification.

Attach the following to the completed form:-

o National Identity Card and or student Identification Card

o End of year Examination results
o Death / Burial certificate where necessary
o School / college Admission letter / Fees stucture
o Birth certificate.
o Voting Card (Parent/Student)

Bomachoge Borabu NGCDF (FY 2022/2023) Page 4