COUNCIL OF GOVERNORS
EMPLOYMENT APPLICATION FORM
ALL APPLICANTS SEEKING EMPLOYMENT MUST FILL THIS FORM
PLEASE NOTE THAT:
1. Applicants are required to fill all the sections
2. It is an offence to willfully give false information on this form
3. The information given may be verified by the Council
4. Applicants are required to provide copies of Academic and professional certificates
and other testimonials; and Identity card or passport.
5. The information provided will be used only for the purpose of vetting and the
Council shall keep it confidential
SECTION A: PERSONAL INFORMATION
1. Position Applied for……………………………………………………………
2. Personal Details
NAME:
Identity No.:
Date of Birth:
Passport No:
Place of birth:
PIN No:
County:
Citizenship:
Constituency:
Gender:
Ward:
Marital Status:
3. Contact Details
Telephone:
Mobile No :
Postal
Address:
Email:
Place
of
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Residence:
Fax:
4. Family Details
Name(s) of Spouse(s) and
Relationship
children
Occupation
ID No.
SECTION B: ACADEMIC AND PROFESSIONAL QUALIFICATIONS
1. Academic & professional Qualifications (start with most recent)
Period
Course
Institution
Reg. No.
2. Training courses attended in the last 2 years (Latest first)
Date/year Course name Place/venue
Skills
where held
acquired
Award
Application/ use of skills
in CoG Work
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3. Conferences / seminars / workshops / study tours / exchange visits attended in the
last 2 years (Latest first)
Date/year Name
Place/venue
Skills
Application/ use of skills
where held
acquired
in CoG Work
4. Membership to professional Associations & Clubs
Period
Association
Membership
Type
Objective
Association
of
Position held
SECTION C: EMPLOYMENT AND WORK HISTORY
1. Employment / Work History (start with most recent & provide contact details where
possible)
Period
Organization
Job Title
Postal Address
Telephone
SECTION D: WORK PERFORMANCE
2. Indicate your duties and responsibilities in current post/employment
I.
II.
_________________________________________
_________________________________________
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III.
_________________________________________
IV.
_________________________________________
V.
_________________________________________
VI.
_________________________________________
VII.
_________________________________________
3. State key programmes/ activities that you have been directly involved in and
summarize key achievements (starting with latest year).
S/No Year Program /activities Summary of achievements
implemented
Remarks/
Challenges/
Mitigating factors
SECTION E: INTEGRITY AND ETHICAL ISSUES
1. Are there any complaints against you in any or all of the following areas? Gross
Misconduct, Professional misconduct, Criminal/corrupt practices?__________ If Yes
kindly provide the details below
Date of complaint or Type of Offence /
Details
Action Taken
Accusation
complaint
2. Have you ever been arrested , charged or convicted for any criminal offence
(excluding minor traffic offences) ___________ If yes kindly provide the details
below
Date
Type
of
Date Charged in
Arrested
/
Details
Outcome
Offence/suit
court
sued
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3. Have you ever been investigated for a criminal offence, corruption offence or breach
of a code of conduct by any organization or agency?
_________. If YES, Provide the details below.
Investigating
Details
of
Period
Type of Offence
Outcome
Organization
Offence
4. Have you ever been a subject of any disciplinary processes, dismissed from
employment, suffered pecuniary embarrassment or declared bankrupt?
_______________ If YES, provide the details below.
Period
Organization
Type of Offence
Details
Outcome
5. Have you ever been involved or accused of conflict of interest
between your personal and official duties? _____ If YES, provide the details below.
Perceived
/
Period
Actual
Organization
Details
Outcome
Conflict
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6. Have you ever received a gift or benefit whose value exceeds Kshs 20,000 while
serving as a public/state officer?________________ If yes please provide the details
below.
Item Type gift / Value
/
Giver
Reasons
Any remarks
benefit
Details
7.
Have you participated in other gainful employment which conflicted with your public
duties? If yes please provide the details below.
Period
8.
9.
Organization
Position Held
Additional Details
Are you an official of any political party? ___________________ If yes provide
details. ____________________________
Do you hold any other citizenship? _______ if yes provide the details below.
Country
Date
Acquired
Citizenship
Reason citizenship acquired
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NB: Should an applicant require more space you may attach additional write up. Kindly ensure
additional material is firmly appended to the form.
OATH AND AFFIRMATION
I solemnly swear /affirm and certify, under penalty of false declaration under the Oaths and
Statutory Declaration Act (cap 15 laws of Kenya) that all the foregoing statements in this
declaration are true and correct to the best of my knowledge.
Dated at ___________ this_________day of____________20__
FOR OFFICIAL USE ONLY
1. Suitable
2. Not Suitable
Suitability
Status:
Reasons / Comments:
Date :
Officer :
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