REPUBLIC OF KENYA
MINISTRY OF EDUCATION, SCIENCE AND TECHNOLOGY
Jogoo House B
Harambee Avenue
P.O. Box 30040
NAIROBI.
Telegrams: EDUCATION-NAIROBI
Telephone: Nairobi 318581
Fax: 214287
FORM A
SECONDARY SCHOOL BURSARY APPLICATION FORM(SESBAF)
YEAR
CONSTITUENCY
DISTRICT
DIVISION
LOCATION
SUB-LOCATION
WARD
VILLAGE/ESTATE
PART A: STUDENTS PETERSON DETAILS
1. FULL NAME:
..
Last
First
Middle
2. Sex
Male ( )
3. Date of Birth
Female ( )
Adm No
Class
4. Name of school..Year
For those students joining Form 1: (please attach Joining Instructions)
a) School admitted: National
Provincial
District
b) Former Primary School Headteacher
Student/Pupil Conduct: Excellent
V.Good
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
For students either joining Form 1 or continuing in Form 2, 3 or 4
Total fees
Paid/able to raise
Outstanding Balance
Kshs
Kshs
Kshs
PART B: FAMILY INFORMATION
1) Tick Appropriately
Both parents Dead
One parent Dead
Both parents alive
Single parent
Any Disability
(Attach support document e.g. death certificate, letter explaining disability or other
disadvantage/circumstance from chief, religious leader, prominent reference).
Fathers/Guardians Name.
Occupation/Profession
Mothers/ Guardians Name..
Occupation/Profession
2) How many brothers and sisters do you have?
3) How many children does the guardian have?
4) How many are working/in business/farming?
5) How many are in Secondary Schools?
6) How many are in Post Secondary Intuitions?
7) If both parents are not alive, who has been paying for your education? (Tick)
(For continuing students)
Guardian
Sponsor/Well wishers
Any other (specify)
8) Have you ever benefited from the Constituency Bursary Fund?
Yes
No
9) If yes, state the Amount
Kshs
EITHER:
CHIEF/SUBCHIEF
Comment on the status of the family/parent
I certify that the information given above is correct
Name:
Position/Designation
Signature
(Official stamp)
Date
OR: RELIGIOUS LEADER
Comment on the status of the family/parent
I certify that the information given above is correct
Name:
Signature
(Official stamp)
Date
Position
PART C: INFORMATION ABOUT FAMILY FINANCIAL STATUS
1. GROSS INCOME IN THE LAST 12 MONTHS (KSHS)
Father
Mother
Guardian/Sponsor
GROSS
INCOME
2. APPLICANTS SIBLINGS IN EDUCATIONAL INSTITUTIONS
SIBLINGS
NAME OF
YEAR
TOTAL FEES PAID OUTSTANDING
NAME/GUARDIANS INSTITUTION OF
FEES
BALANE
CHILDREN
STUDY/
CLASS
GRAND TOTAL
PART D: DECLARATION
1. STUDENTS DECLARATION
I declare that to the best of my knowledge the information given herein is true.
Students Signature
Date
2. PARENTS/GUARDIANS DECLARATION
I declare that I have read this form/this form has been read to me and I confirm that the
information given herein is true to the best of my knowledge.
Parents/Guardians Name
Parents/Guardian Signature......
Date
3. SCHOOL VERIFICATION
a) For continuing students
Year:
Position in class/Form
(Attach a report form)
Term 1
Term 2
Term 3
Student Discipline (Tick one option only)
Excellent
V.Good
Good
Fair
Poor
Headteacher as brief comments on students level of need, discipline and academic
performance.
I declare that the above named is astudent in this school
Headteachers Name
Signature
Date and School Stamp
...
PART E: FOR OFFICIAL USE ONLY BY THE CONSTITUENCY BURSARY COMMITTEE
SCORE:
Approved for Bursary
Not Accepted for Bursary
Reasons:
Bursary awarded Kshs.
Chairmans Name
Signature
Date
Secretarys Name
Signature
Date
Official Stamp