READ THE INSTRUCTIONS BEFORE COMPLETING THIS FORM.

COMPLETE ALL APPROPRIATE SECTIONS IN CAPITAL/BLOCK LETTERS AND RETURN WITH YOUR NON-REFUNDABLE APPLICATION FEE (See Fee Schedule) AND OTHER SUPPORTING DOCUMENTS TO:

1. APPLICANT’S DETAILS

FULL NAMES

(as per secondary school

certificates or its equivalent)

TITLE MR [ ] MRS [ ] MS [ ] GENDER Male [ ] Female [ ]

DATE OF BIRTH NATIONALITY. NATIONAL ID/PASSPORT NO.

COUNTY SUB- COUNTY LOCATION

2. PERMANENT ADDRESS

P.O.BOX EMAIL

MOBILE PHONE TOWN

3. NEXT OF KIN

NAME RELATIONSHIP

CELL PHONE ADDRESS

P.O.BOX EMAIL

4. EDUCATIONAL BACKGROUND: a. Secondary Education

INSTITUTIONS ATTENDED FROM (YEAR) TO (YEAR) CERTIFICATE AWARDED MEAN GRADE

b. Post-Secondary Education

INSTITUTIONS ATTENDED FROM (YEAR) TO (YEAR) CERTIFICATE/DEGREE AWARDED CLASSIFICATION

5. EDUCATIONAL PLANS (tick appropriate)

APPLICATION FORM

MKU/EQUIP/F002

The Programs Coordinator, Equip Africa Institute, Mount Kenya University, Nairobi Campus 5th Floor - Union Towers, Moi Avenue, P.O Box 13495 - 00100, Nairobi Tel:+254202 187 379 / 0703 591 299 or email to chrp@mku.ac.ke

1. PROGRAM APPLIED FOR CHRP I [ ] CHRP II [ ] CHRP III [ ]

2. PROGRAM LEVEL

APPLICATION NO:………………………………………………….. APPLICATION FEES RECEIPT NO./CHEQUE NO……………………………………………… DATE:…………………………….………………….. NAME:………………….……………………………………………. SIGNATURE ………………………….……..

www.mku.ac.ke

Signature :…………………………………………………………………. Date.: ………………………………………………………………………………………….

I hereby certify that the information given in this application is correct and complete to the best of my knowledge, and hereby give my permission to the CHRP Program Coordinator to obtain any verification deemed necessary to process my application. I further certify that I will arrange for the forwarding of official

transcripts as requested in the instructions, and that transcripts become the property of Mount Kenya University and will neither be forwarded to another

institution nor returned to me. I will include with this application my application fee receipt and other documents as required in the application instructions.

BANK DETAILS:BANK: COOPERATIVE BANK OF KENYA BRANCH: THIKA ACCOUNT NAME: EQUIP AFRICA INSTITUTE ACCOUNT NUMBER: 01129558232700

MKU/EQUIP/F002

SIGN YOUR APPLICATION FORM BEFORE RETURNING IT TO MOUNT KENYA UNIVERSITY. APPLICATION CHECKLIST 1. Non-refundable application fee Kshs. 1,000/-

8. HOBBY

PREFERRED HOBBY

6. CAMPUS WHERE STUDY WILL BE UNDERTAKEN

[ ] MAIN CAMPUS- THIKA [ ] NAIROBI [ ] MOMBASA [ ] ELDORET [ ] NAKURU [ ] NKUBU [ ] KITALE [ ] KAKAMEGA

[ ] KISII [ ] KIGALI [ ] KISUMU [ ] KERICHO [ ] GARISSA [ ] MALINDI [ ] HARGAISA [ ] NYERI

7. FINANCING OF STUDIES.

Please Tick [ ]SELF [ ]PARENTS/GUARDIAN [ ]GOVERNMENT/HELB [ ]OTHER SPONSORSHIP

Payment can also be made directly to the following bank accounts:

ONLY DULY FILLED APPLICATION FORMS WILL BE PROCESSED.FOR OFFICIAL USE ONLY

Mount Kenya University RESERVES THE RIGHT OF ADMISSION More information may be obtained from the CHRP Coordinator, Equip Africa Institute, Mount Kenya University

*No cash payment2. Duly filled and signed application form. 3. Copies of all academic certificates including secondary school certificates, Bachelors, Diploma & Certificate level transcripts and certificates. 4. Two (2) recent passport size photograph (write your name on reverse side) 5. Copy of national I.D/Passport. ADDITIONAL REQUIREMENTS FOR INTERNATIONAL STUDENTS 1. An official translation of academic records (where language of study is not English)

Radio [ ] Television [ ] Newspapers [ ] Friends [ ] Career Exhibitions [ ] Others State ………………………………………….....................................................................................11. ATTESTATION.

4. PREFERRED INTAKE January[ ] June[ ]

3. MODE OF STUDY Weekday evenings [ ] Executive Saturday [ ]

9. STATE WHETHER YOU HAVE ANY SPECIAL NEEDS THAT REQUIRE SPECIAL ATTENTION

Please Tick Yes [ ] No [ ] If yes, State the need: ……………………………………………………………………………………………..

10. INDICATE HOW YOU LEARNT ABOUT THE MOUNT KENYA UNIVERSITY CHRP PROGRAM

*Payment is to be made via electronic money transfer or bankers cheque payable to Equip Africa Institute. * Money once paid is non refundable unless under special consideration.

CONDITIONS OF ACCEPTANCEI. Pay a Non – refundable application fee for the course chosen (Attach bank slip)II. Attach certified copies of Relevant Academic Certificates, copies of your National ID, copies of your birth certificate and affix two (2) passport size photos with your names clearly written at the back.