HRCMO/MSHCO

HUMANITARIAN RELIEF & CHARITY MISSION TO ORPHANS.

MISSION DE SECOURS HUMANITAIRE ET CHARITE POUR LES ORPHELINS.

SELF HELP

B.P: L’SHI, D.R.CONGO, PO.Box 00200 NAIROBI KENYA , TEL: +243 81 211 6835,

web sites : www.reliefandcharity.cfsites.org,

Email: reliefandcharity1@yahoo.com, reliefandcharity1@gmail.com,

STRATEGIES des efforts personnel. Congratulations on your great choice. ONGD Reg. No 211/454/04

N°: BPCP/HRCMO/MSHCO/3110/2017

TRANSMIS COPIE pour information aux :

-Bureau général de la HRCMO

-Messieurs les Délégués Provinciaux de la MSHCO (tous)

-Messieurs les délégués des missions (tous) - --- -Messieurs les directeurs des départements (tous)

- Messieurs les coordinateurs (Tous)

WELFARE DEVELOPMENT COMMITTEE Please complete this form in Capital Letters and in Blue or Black ink and return to THE ADRESS ABOVE. BURSARY APPLICATION FORM YEAR20…________,DISTRICT________________,DIVISION______________LOCATION______________________,SUBLOCATION_________________________ Branch/GROUP/ORGANISATION from:_____________________________________________ PART A: STUDENT’S/PERSONAL DETAILS. 1. Full Name: ____________________ _________________. ________________ Last first middle 2. Gender: Male ( ) Female ( ), Fax____________ Mailing address______ 3. a) Date of Birth (dd/mm/yy)____./_____./________ Admission No____________ 4. Name of the School/College/University__________________________________ Class/Course_______________________________________________________ 5. Telephone___________________, Email________________________________ 6. ID/PP___________, NSSF No__________, PIN No__________, NHIF No_____ a) For continuing Students Year_______________________, Residential address___________ Last term/Semester report (attach copy of report form) b) For new students Year____________________________ School/College/University admitted_____________________________________ Total Fees, paid/able to raise, outstanding balance, US $......... US $..................... US$....................... c) Bursary awarded from other sources US $________________________________ d) Loan awarded ______________________, Amount solicited to us____________ 5. FAMILY INFORMATION i) Are your parents both alive? Yes No ii) Is your parent alive? Yes No (for single parent, if not attach photocopy of death certificate or report from sub-chief). __________ Father’s name______________________________ Occupation____________________ Mother’s name_____________________________ Occupation_____________________ How many brothers and sisters do you have? How many are working/Business?.......... Civil Status (tick one): Married O, Single O How many are in secondary School? Divorced O, Separated O How many are post-Secondary institution? Widowed O If both parents are alive, who has been paying for your education? (Tick one) (for continuing students. Guardian Sponsor/ Well wishers PART B: INFORMATION ABOUT FAMILY FINANCIAL STATUS. 1. Gross income in the last 12 months US $______________________________ FATHER MOTHER Guardian/Sponsor TOTAL GROSS INCOME Gross income: (This means income from salary, Business and farming) 2. APLICANT’S SIBBLINGS AND EDUCATIONAL INSTITUTION Sibling’s name Name of institution Year of study or class Total Paid Fees Paid Outstanding balance Grand Totals PART C: DECLARATION 1. STUDENT’S DECLARATION I declare that the information given herein is true to the best of my knowledge. Students signature:___________________________ Date_________________________ 2. Parents/Guardian declaration. I declare that I have read this form has been read to me and I hereby confirm that the information given is true to the best of my knowledge. Parent’s/Guardian’s signature…………………. Date……………………………. 3. School/college/ University verification Student Conduct: Excellent Very Good Good Fair Poor I declare that the above named is a student in this school/ college/university(name of institution, signature, Date and stamp)_________________________________________