BURSARY APPLICATION FORM STUDENTS PERSONAL INFORMATION Full Names: .................................................................................................................................. Gender……………………………………..Date of Birth…………………………………………………………………………. Home Address………………………………………………………………………………………………………………………….. Masjid Near you…………………………………………………………………………………………………………………………………….. (where you live) Telephone Estates Town county Mobile Email: ……………………………………………………………………………………………………………………………………….. Marital Status: …………………………………………………………………………………………………………………………. If married: Name of Spouse: ……………………………………………………………………………………………………………………… Number of Children (if any) ………………………………………………………………………………………………………. Do you have a job yes No. Name of Employer: ……………………………………………………………………………………………………………………. Address: ……………………………………………………………………………………………………………………………………… Monthly Income ………………………….. Kshs. Other Income……………………………… Religious Background Religion: Muslim If Muslim: By Birth Christian Other: . Conversion If converted: by whom……………………….when………………………mosque…………………………………………………. FAMILY INFORMATION Father’s Name……………………………………………………………………………………………………………………………………….. (First Name) (Middle) other Names. Nationality…………………………………………………… I.D No………………………………………………………………………………. Telephone………………………………………………………………………………………………………………………………………………… Occupation………………………………………………………………………………………………………………………………………………. If Employed: Name of Employer ………………………………………………………………………………………………………… Sources of Income………………………………………………………………………………………………………………………………… Monthly Income Kshs……………………………………………………………………………………………………………………………. Religion ………………………………………………………………………………………………………………………………………………….. Mother’s Information Name………………………………………………………………………………………………………………………………………………………… (First name) (Middle) other names. Nationality………………………………………………………… I.D No…………………………………………………………………………… Telephone…………………………………………………………Postal Address……………………………………………………………….. Occupation…………………………………………............ if Employed, Name of Employer………………………………………. Sources of Income……………………………………………………………………………………………………………………………………. Monthly Income: Kshs……………………………………………………………………………………………………………………………… Religion……………………………………………………………………………………………………………………………………………………. School Information Please attach all relevant copies of certificates and testimonials Previous schooling Name of your previous school……………………………………………………….. Postal address………………………………………………………………………………… Telephone……………………………………………………………………………………… Date of Admission………………………………….. Date you left……………………………………. Final results………………………………………………………………… Current School Name of Current school: ……………………………………………………………………………………………… Full Address…………………………………………………………………………………………………………………… Telephone…………………………………………………………………………………………………………………………… Class/Form/Year: …………………………………………………..Course Study………………………………………. National/International Exams you will be sitting …………………………………………………………………… Date of Joining……………………………………………………………………………………………………………………………. Has your education been financed to date?................................................................................... Sponsorship Required Please indicate the amount of sponsorship required under each category listed below. Registration fee………………………………………….. Tuition fee………………………………………………….. Examination fee…………………………………………… Activity fee …………………………………………………… Medical ……………………………………………………….. Student card …………………………………………………… Boarding fee……………………………………………………. Any other………………………………………………………… Total = …………………………………………………………………. Please briefly state why you need the sponsorship? ………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………… How long is the sponsorship required? ………………………………………………………………………………………………….. Referee Recommendation Name ………………………………………………………………………………………………………………………………………………………. First Middle Last Address…………………………………………… Tel. …………………………………………………………………………………. Occupation/kazi ……………………………………………………………………… I have read the information in this other forms and it is true and I would recommend you to consider his application. ……………………………… / …………………………………………………. Sign Date Checklist and Rules/Regulation Please attach the entire requirement below to the application forms: i. 1. Passport size photograph 3 ii. iii. iv. v. vi. vii. A copy of your birth certificate/ I.D A copy of your parents / guardians I.D Recommendation letter Copies of awards, honors and certificates received. Copies of your last scores for any test/ exam done or report form. Fee structure for the course study/school. Application forms should be addressed with all supporting documents to COMMITTEE, PWANI ONE SHILLING FOUNDATION. P.O BOX 81267-80100 GPO MOMBASA For official Use Received by…………………………………………………………….. Date. ……………………………………………… 1. Checked by………………………………………………. Date………………………………………………….. 2. Checked by……………………………………………….Date……………………………………………………. 3. Checked by……………………………………………….Date…………………………………………………….. RECEIPT NO……………………….. Date………………………………………. Remarks. ………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………. Final Remarks …………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………..
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