Kenya Pipeline Company has advertised Scholarships for KCSE candidates, which are dubbed “Inuka Scholarship Programme”.Only KCPE finalists are required to apply
INAUGURAL KPC DISABILITY INUKA SCHOLARSHIP PROGRAMME
2017 APPLICATION FORM
INSTRUCTIONS/GUIDELINES
This form is NOT for sale.
The information provided in this form is for assessment of the applicant’s academic and financial capacity for the purpose of consideration for scholarship/award.
This application form must be duly filled in CAPITAL LETTERS.
When invited for interview, the applicant MUST bring the originals of all documents attached.
Incomplete or inaccurately filled forms will be automatically rejected.
Canvassing will lead to automatic disqualification.
The completion and submission of this form is not a guarantee for sponsorship.
False statements, omissions or forged documents will lead to automatic disqualification.
Kenya Pipeline Company reserves the right to make the final determination of scholarship beneficiaries.
Only 2016 KCPE candidates will be considered.
Every part of this form must be filled. Failure to do so makes this application form incomplete and renders the applicant ineligible for the scholarship.
Only shortlisted candidates will be interviewed.
PART A: APPLICANT’S PERSONAL INFORMATION
PERSONAL DATA
Full name of applicant:
First: __________________ Middle: _______________________Surname/Family name________________
Gender: Male
Female
Date of Birth:
D
D
M
M
Y
Y
Y
Y
Disability:
Type of Disability: _____________NCPWD Registration No.:
N
C
P
W
D
/
P
/
(attach a copy of disability card)
Do you use any assistive device: Yes
No
If yes, name the device: _____________________________
Do you need any assistive device to help you with your secondary school education? Yes
No
If yes, describe the assistive devices_____________________________________________________________
Postal Address: P.O. Box
Tel/Mobile No.
Alternate Mobile No.
Physical Address: County _________________________Sub-County __________________________________
Division_________________ Location_____________________ sub location___________________________
ACADEMIC INFORMATION
Name of primary school attended (where you sat 2016 KCPE): ________________________________________
Postal Address: P.O. Box
Tel/Mobile No.
Alternate Mobile No.
Physical address: County: _______________________________ Sub County_______________________
Division: __________________ Location : _____________________ Sub Location: _______________________
K.C.P.E
Index
No
K.C.P.E Results: ___________________
(Attach copy of results slip or one provided by the Head teacher of your former school with his/her certification) Year sat for KCPE:________________
Have you attempted KCPE in previous years?
Yes
No
If yes, how many times and why? _______________________________________________________________
PART B: APPLICANT’S FAMILY INFORMATION
PARENT’S INFORMATION
Father’s Full Name:
First Name: ___________________Middle Name: _________________Name Surname: ________________
ID No.
Living:
Deceased:
[If deceased please attach copy of death/burial certificate]
Physical Address: County: _____________________________ Sub-County: _____________________________
Division: _________________ Location: _____________________Sub-Location ________________________
Postal Address: P.O. Box
2 of 7
Tel/Mobile No.
Occupation: _______________________________________________________________________________
Mother’s Full Name:
First Name: ___________________Middle Name: _________________Name Surname: ________________
ID No.
Living:
Deceased:
[If deceased please attach copy of death/burial certificate]
Physical Address: County: _____________________________ Sub-County: _____________________________
Division: _________________ Location: _____________________Sub-Location ________________________
Postal Address: P.O. Box
Tel/Mobile No.
Occupation: _____________________________________________________________________________
Are your parents living together? Yes/No (If no please explain): ____________________________________
__________________________________________________________________________________________
GUARDIAN INFORMATION (If not living with parents)
First Name: ____________________ Middle Name: __________________ Surname: _____________________
ID No.
Relationship to student/applicant: ___________________________
Physical Address: County: ________________________ District: _____________________________
Division: ___________________ Location: ___________________Sub-Location: ________________________
Postal Address: P.O. Box
Tel/Mobile No.
Occupation________________________________________________________________________________
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PART C: APPLICANT’S EVIDENCE OF NEED
APPLICANT’S INFORMATION
Indicator
Description
Why are you applying for a scholarship?
Have you received any financial support/bursaries in the past? Please provide documentation.
Do you have any special needs? For example chronic illness, etc. Please provide documentation.
Any other cause for special needs? Describe.
Who do you live with? Parent(s)
Guardian(s)
PARENT/GUARDIAN INFORMATION
Indicator
Father/Male Guardian
Mother/Female Guardian
Age of your parents/guardians:
Does any of your parents have a
disability?
If
yes, describe
the
disability.
Does any of your parents/guardians
suffer from a chronic disabling
medical condition? If yes, describe.
Are you living with both parents?
If
not, explain.
Are
your
parents/guardians
employed? If yes, give details
of
job and salary per month. Attach
copy of pay slip.
Do your parents/guardians own a
business? If yes, describe and show
the average monthly income. Attach
bank statement.
Do
your
parents/guardians
own
land? If yes, state number of acres,
type
of crops
grown, number
of
4 of 7
cows/sheep/goats/donkeys and income from such assets.
Do your parents/guardians have any other assets or sources of income, including casual labour? If yes, indicate the approximate monthly income.
FAMILY INFORMATION
Indicator
Description
Has your family been affected by civil conflict or natural disasters such as displacement, flooding, drought, fire or famine?
Describe: What type of house do you live in?
Please describe any other cause of disadvantage or vulnerability?
Any siblings in: i) Secondary School:
University:
PART E: DECLARATIONS
APPLICANT’S DECLARATION
I, _________________________________________ declare that the information given above is true to the best of my knowledge and I am aware that giving false representation will mean that the application will not be considered and will lead to automatic disqualification.
I authorize Kenya Pipeline Company Disability Inuka Scholarship Programme or its representatives to obtain such additional information concerning my education and financial records as needed to complete this scholarship application.
In the event I win the scholarship, I commit myself to working hard and posting excellent results throughout my secondary school course.
Signature: ________________________________________ Date D D M M Y Y Y Y
PARENT’S/GUARDIAN’S DECLARATION
I confirm that the above information is true to the best of my knowledge and I am aware that giving false representation will mean that the application will not be considered and will lead to automatic disqualification.
On behalf of my child, I authorize Kenya Pipeline Company or its representatives to obtain such additional information concerning this applicant’s education and financial records as needed to complete this scholarship application.
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Parent/Guardian:
Name: ________________________________Signature: _____________Date:
D
D
M
M
Y
Y
Y
Y
Part F: RECOMMENDATIONS
This part must be completed by the relevant authorities indicated. Any false information will lead to disqualification.
Primary School Head Teacher:
Please report on the above named applicant’s performance, conduct, special needs and talents. Also explain why he/she should be considered for the Kenya Pipeline Company Disability Inuka Scholarship Programme:
How long have you known the candidate/family? _________________________________________________
Rate the candidate’s financial ability:
Rich
Middle Class
Low Income
Very Needy
Needy
I have reviewed the information given in this form and believe it to be truthful. The above named student attended my school. Based on my knowledge and/or inquiries, I can affirm that he/she is needy/vulnerable based on the facts provided about his/her circumstances.
Name: ___________________________Signature_________________ Official stamp: ___________________
Date: _________________ Address: P.O. Box: _________________________
Tel/Mobile Number: ________________________
Provincial Administration (Chief or Asst. Chief).
How long have you known the candidate/family?
_______________________________
Rate the candidate’s financial ability:
Rich
Middle Class
Low Income
Very Needy
Needy
I have reviewed the information given in this form and believe it to be truthful. The above named student is a resident of my location/ sub-location. Based on my knowledge and/or inquiries I can affirm that he is needy/vulnerable based on the following facts about his/her circumstances.
Name: _____________________________________ Signature & Official Stamp: ________________________
Date_____________________________________
Mailing Address: P.O. Box: Tel/Mobile Number: _________________________________________________
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Religious Leader (bishop, pastor, priest, imam, etc.)
How long have you known the candidate/family? _________________________________________________
Rate the candidate’s financial ability:
Rich
Middle Class
Low Income
Very Needy
Needy
I have reviewed the information given in this form and believe it to be truthful. Based on my knowledge and/or inquiries I can affirm that this student is needy/vulnerable based on the facts provided about his/her circumstances.
Name: ____________________ Signature & Official Stamp: __________________
Date: D D M M Y Y Y Y
Mailing Address: P.O. Box _________________________ Tel/Mobile Number: __________________________
NB: If a family is found to have misrepresented their circumstances, the scholarship will be terminated and they will be required to refund fees paid.
END
Click on the link below to download application form
kpc-scholarship
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