African Canadian Continuing Education Society

TIVET / College / University Scholarship 2024 Application Form

P.O. Box 707 – 50100, Kakamega
Milimani Estate Off State Lodge Road at Vaghela Premises
jancered@acceskenya.org www.acceskenya.org Phone 0727-210-532

INSTRUCTIONS
 This form should be completed by the applicant and if any person makes a false statement relating to the request for a
scholarship, they will be disqualified by ACCES.
 This scholarship only applies to bright and needy undergraduate (KUCCPS) students in TIVET, university and college
accredited by either KUCCPS or KNEC. Post-graduate students are not eligible. Any student wishing to be considered for a
scholarship must meet the eligibility criteria, submit a fully completed and signed application form, and include copies of
academic certificates and supporting documents as required.
 Complete all sections in CAPITAL/BLOCK LETTERS using black ink. A (*) indicates that supporting documents are required.
Please print clearly.
 This application form should be submitted to ACCES office by 30th April 2024 at 5:00 p.m. using the above address,
otherwise it will be marked as late and will not be considered for the partial scholarship.
 ACCES scholarships are only available to students who are residents of Kakamega, Bungoma, Busia and Vihiga
counties.

SECTION A- APPLICANT INFORMATION

Full Name
ID NUMBER* (Attach a copy of ID Card)
Date of Birth__________________________ Gender (please circle) FEMALE MALE
Email Mobile # ______________________
Permanent address Postal Code__________________________
Sub-county Village______________________________
County (circle) BUNGOMA, BUSIA, KAKAMEGA, VIHIGA
KCPE Marks*__________________________ K.C.S.E Grade*__________________________
Program type (circle) TIVET / COLLEGE / UNIVERISTY
Name of Institution______________________ Registration Number_______________________
Course________________________________ Level___________________________________
Deferred? YES* / NO Reason
Fees required?* _______________________ Outstanding fee balance?* ___________________
Physically disabled: YES* of NO Specify
NB: This document is not for sale. This application form can be photocopied and distributed freely.

Date:________________________ Applicants Signature:

For office use only – applicants do not write in the section below:
Applicant’s application number Status
Comments / Questions

SECTION B-TYPE OF FAMILY

Number of people in household

Tick all that apply Polygamous _____ Single Parent _____ Monogamous _____ Other (Specify) _____

SECTION C-FAMILY BACKGROUND

Applicants’ status Total Orphan _____ (Attach copies of death certificate / burial permit)

Partial Orphan _____ (Attach copies of death certificate / burial permit)

Both parents alive _____ (Attach copies of parents’ identification)

Other (single parent) _____ (Provide explanation: Attach copies of parent identification)

Explanation if necessary:

Occupation & income of:

Father_________________________ Mother________________________ Guardian_______________________

Economic activities practiced by parents: ______________________________________________________________________

________________________________________________________________________________________________________

If farming, what is the size of your land? _________________________

Which crop do you grow? _________________________________________________________________

Family’s total income per month

Siblings currently in school

(Attach evidence*)

List the names of institutions your What type of school is it? (Specify if Which class, form or year are they in?
siblings are attending starting with the college, primary or secondary, public,
eldest private, day, district, provincial or
national)

Pg. 2 NB: ACCES 2 FORM “ IS NOT FOR SALE Applicant’s Signature

SECTION D-HOUSEHOLD SITUATION

Is your main house permanent or temporary? _______________________ Number of rooms ______ Type of floor ______
Provide an explanation of living situation:

SECTION E-APPLICANTS EDUCATIONAL BACKGROUND

School Level Institution Name School Years School type (Specify if public KCPE/KCSE
Location Attended or private or if day, district,
national)
Primary
Secondary
Postsecondary

SECTION F-APPLICANTS COURSE DETAILS

Name of University/College

Level of training: Certificate ____ Diploma ____ Bachelor’s ____ Course Title

Admission/Registration Number Year of Study

Faculty/School Department

Duration of Study (Month/Year to Month/Year) Presently enrolled? YES NO

If enrolled, then what is your current academic performance?* (Attach a copy of your college transcripts or report forms)

If no, then explain why you have been admitted, but not enrolled in class.* (Attach admission letter)

SECTION G-APPLICANT’S FINANCIAL STATUS

What is the cost of the program per academic year for tuition and fees* in KSH? (attach fee structure)?

List all loans or sponsorship that you have already been awarded
Type Amount KSH Year Awarded Continuing or one time
HELB
Bursary
CDF
Other

Pg. 3 NB: ACCES 2 FORM “ IS NOT FOR SALE Applicant’s Signature

SECTION H-APPLICANT’S PERSONAL STATEMENT

1. How and when did you know about ACCES and the scholarship opportunity?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
2. Briefly explain your personal background, and any special personal or family circumstances necessitating your need for an
ACCES scholarship
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
_
3. What are your personal aspirations?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

SECTION H-APPLICANT’S PERSONAL STATEMENT continued

4. What are your career plans once you have this education?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
5. Discuss the future contributions you will make to ACCES if awarded the scholarship.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
6. Is there any other information that the scholarship review committee should be aware of?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

Pg. 4 NB: ACCES 2 FORM “ IS NOT FOR SALE Applicant’s Signature

 SECTION I- REQUIRED DOCUMENTS CHECKLIST

Required documents:  Documents that may be required: 

Applicants birth certificate Transcripts (if currently attending)

Applicant’s ID card Statement of outstanding balance
KCPE Certificate Deferral letter
KCSE Certificate Medical report for applicant
Institution admission letter Medical report for parents
Fee Structure of institution Parent’s ID card if living
Death certificates / burial permits if passed

Pg. 5 NB: ACCES 2 FORM “ IS NOT FOR SALE Applicant’s Signature

 SECTION J- APPLICANT’S DECLARATION

I ___________________________________________________ certify that the information given in this application is both

complete and accurate to the best of my knowledge and I have confirmed that all the documents necessary to verify the
information are attached. I understand that any misrepresentation will impact my eligibility to be considered for and / or
receive financial support.

Signature Date (DD/MM/YYY)

Draw a roadmap to your home indicating major landmarks and a well-known name of a family member

Sa

SS

Sample of how to draw your map

Kakamega

Munzatsi

Ask for Peter Shivisi

Jebluk Primary Home

Pg. 6 NB: ACCES 2 FORM “ IS NOT FOR SALE Applicant’s Signature