MASENO UNIVERSITY OFFICE OF THE REGISTRAR—ACADEMIC AFFAIRS ============================================================ Tel: 254-057-51622,51620,51008,51011 Private Bag Fax: 254-057-51221,51153 MASENO Website: www.maseno.ac.ke

AFFIX PASSPORT SIZE PHOTO

Application No.——————–

NOTE: i. That the completed from should be submitted to the ACADEMIC REGISTRAR, MASENO UNIVERSITY, PRIVATE BAG, MASENO;PRINCIPAL CITY CAMPUS COLLEGE, BOX 3275 – 40100,KISUMU;COORDINATOR, HOMA-BAY TOWN LEARNING CENTRE, BOX 716 – 403000,HOMA-BAY That all candidates applying must attach copies of their certificates/transcripts, Identity Card/Waiting Card/Birth Certificate, Original Receipt for purchase of the form. That applicants should indicate the campus of interest: whether Kisumu City Campus College (Day/Evening/Weekend/School based); Homa-Bay(Day/Evening/Weekend/School based) or Maseno Campus (Regular) iv. V 1 PERSONAL DETAILS Other names in full:————————— Date of Birth:————/—————/—— Day Month year Gender: Male————— Female —— Marital Status: Married: ——————— Nationality:——————————— Country of origin:——————————
Address for correspondence

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That information will be sent only to successful candidates. That the names appearing on this from should be the same as those in your certificates.

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Single:—————————— Telephone:———————–--

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PROGRAMMES APPLIED FOR (Tick as appropriate) 1. CERTIFICATE [ ] 2. DIPLOMA [ ]

CERTIFICATE / DIPLOMA applied for:_____________________________ ____________________________________________________________

____ MODE OF STUDY: [ ] DAY (FULL TIME) [ ] EVENING [ ] WEEKEND [ ] SCHOOL-BASED CAMPUS / LOCATION CHOICE: [ ] KISUMU CITY CAMPUS COLLEGE [ ] HOMA-BAY TOWN LEARNING CENTRE 3. i ACADEMIC BACKGROUND KENYA CERTIFICATE OF SEONDARY EDUCATION KCSE/KCE/EACE or equivalent Examination passed candidate offering alternative qualifications must attach copy (s) of certificate (s). Last Secondary School attended:——————————————Date of Admission ————— Date of completion——————Year of Examination ———— Index Number ———————— Examination body——————————————————MEAN GRADE ————————— POINTS—————— SUBJECT GRADE —————————————————————————————— —————————————————————————————— —————————————————————————————— —————————————————————————————— —————————————————————————————— —————————————————————————————— —————————————————————————————— —————————————————————————————— KENYA ADVANCED CERTIFICATE OF EDUCATION (KACE) EAACE or equivalent.(write N/A if Not Applicable) High School attended:——————————————— Date of Admission ——————— Date of Graduation —————– Year of Examination —————— Index Number —————— Examination body ————————————Result: Principal Pass (es) —————————– Subsidiary (es)———— SUBJECT ———————————————————— ———————————————————— ———————————————————— ———————————————————— ———————————————————— GRADE ———————————— ———————————— ———————————— ———————————— ————————————

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PROFESSIONAL OR OTHER QUALIFICATION (s) Give details where obtained, dates and certificate (s) awarded. (Attach documentary proof).
Qualifications Where obtained

Dates

Award

EMPLOYMENT HISTORY (IF APPLICABLE) List all relevant work experience: previous and current DATES OF EMPLOYMENT FROM TO JOB TITLE

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I declare that all statements on this application form and any material filed in support here of are true, correct and complete and all required information has been disclosed. I acknowledge that providing incorrect information or withholding relevant information may result in the University withdrawing any offer of a place and that this withdrawal may take place at any stage during the course of study. Signature of Applicant:———————————Date:———————————— ————————————————————————————————————–

FOR OFFICIAL USE ONLY Recommendation of Head of Department Name of H. O. D:——————————Sign :————– Date—————— —————————————————————————————————– Recommendation of the Dean of Faculty:

Name of Dean Faculty/School————————– Sign———–Date———— —————————————————————————————————— Recommendation of Admissions Board:

Admitted/Not Admitted for:———————————————————— Cert/Dip ———— MASENO UNIVERSITY OFFICE OF THE REGISDept.________________ Deferred until ——————Date of Meeting ————————— TRAR—ACADEMIC AFFAIRS ======================== ======================== NOTE: THE University reserves the right to request and obtain further information from any education, ============ institution 254-057Tel: or employer which may be required to confirm or clarify your suitability and eligibility for the course applied for: 51622,51620,51008,51011 Private Bag Fax: 254-057-51221,51153 MASENO