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Letitia Casey
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NOMINATION APPLICANT SELF DISCLOSURE FORM Note: This form must be filled by a Party member when applying for acceptance and clearance by respective organs of Ukweli Party to participate as a

1 NOMINATION APPLICANT SELF DISCLOSURE FORM Note: This form must be filled by a Party member when applying for acceptance and clearance by respective organs of Ukweli Party to participate as a candidate in Party nominations. A. POSITION YOU ARE VYING FOR I, h ereby apply to participate in the Ukweli Party nominations as the Party candidate for the position of.. in the 2017 general elections. COUNTY CONSTITUENCY WARD B. PERSONAL INFORMATION 1) FULL NAME:. 2) CAMPAIGN NAME (if any):... 3) SEX: FEMALE MALE 4) DATE OF BIRTH: (DD/MM/YY):.. 1

2 5) ID/PASSPORT NUMBER:.. 6) VOTER REGISTRATION NUMBER:.... 7) COUNTY CONSTITUENCY WARD... POLLING STATION... 8) CONTACT DETAILS: P. O. BOX CODE TOWN... Tel/Mobile: . 9) Have you ever changed your name? YES NO (If YES) Previous name: From (year) To (year)... C. CITIZENSHIP 1) Are you a Kenyan citizen? YES NO 2) How did you acquire your citizenship: By birth By registration By naturalization 3) List any other country/countries where you are or have been a citizen: 2

3 D. EDUCATION PROFILE (Provide accurate information about the educational institutions you have attended (primary, secondary and tertiary where applicable) and the qualifications/certificates you obtained. Add rows if need be) INSTITUTION YEARS CERTIFICATE/QUALIFICATION from to OBTAINED E. EMPLOYMENT/WORK/OCCUPATIONAL HISTORY (In this section, the Party would like to know your history in respect to employment/work/occupation and your self-assessment of key accomplishments in your work experience. Only describe those you consider key/major/or best reflecting your capabilities. Add rows if need be.) Job held/work done/occupation (e.g. position of employed or type of work/occupation if not employed Affiliation (i.e. organization or selfemployed) YEARS from to Key Accomplishment s F. MEMBERSHIP TO ORGANIZATIONS OR ASSOCIATIONS (List all the organizations or associations that you are or have ever been a member of and the duration of membership. Examples could include professional associations, welfare associations, CBOs, NGOs, Unions, etc. Add rows if need be.) NAME OF ORGANIZATION MEMBERSHIP TYPE (e.g. an official or ordinary member) 3 From (year) PERIOD To (year)

4 G. STATEMENTS OF INTEREST (Questions in this section help you to present the case for your interest to contest for a position as the Ukweli Party candidate and present a pitch of why you. Please stick to the word limits for your statements.) 1) What is your main reason for deciding to run for office? (150 words or less) 2) Why do you feel Ukweli is the Party for you? (150 words or less) 3) Why should voters in your Ward/Constituency/County support your candidacy? (350 words or less). 4

5 H. DISCLOSURES ON CONDUCT AND LIABILITIES 1) Have you been subject to disciplinary actions undertaken by any tribunal or organization? YES NO 2) Have you ever been fired/suspended/discharged/asked to resign from a job? YES NO 3) Have you ever been convicted of breach of rules, regulations or code of conduct of any private organization/association? YES NO 4) Have you ever been convicted of any crime? YES NO 5) Has any partnership or company you have been part of ever been convicted of any crime? YES NO 5

6 6) Does any partnership or company you are part of have outstanding liabilities with any taxation authority in Kenya or elsewhere? YES NO 7) Do you have any outstanding liabilities with a money lending authority in Kenya or elsewhere? YES NO 8) Do you have any outstanding liabilities to any taxation authority in Kenya or elsewhere? YES NO 9) Have you ever been declared bankrupt, filed a petition for bankruptcy, made a compromise or agreement with your creditors or gone out of business leaving debts outstanding? YES NO 10) If yes in (9) above, have you been discharged? YES NO Not Applicable 6

7 I. FULL DISCLOSURE 1) Are you aware of any fact not otherwise asked of you or that you have not disclosed that if publicly known or discovered could jeopardise your chances for election, embarrass Ukweli Party and therefore injure its reputation and bring to question its declared principles, positions and objectives;; or could be used by your opponents against you or the Party? YES NO (If YES, provide details):.... J. QUALIFICATION TO BE A CANDIDATE (This section helps you to ascertain your eligibility to be a candidate for the position you are applying for nomination.) THE CONSTITUTION OF KENYA ARTICLE 99 AS ARTICLE 193 COUNTY QUALIFICATION AND DISQUALIFICATIONS FOR ELECTION A MEMBER OF PARLIAMENT QUALIFICATIONS FOR ELECTION AS A MEMBER OF ASSEMBLY THE ELECTIONS ACT 2011 ARTICLE 22 ARTICLE 23 AS A ARTICLE 25 AS A QUALIFICATIONS FOR NOMINATION OF CANDIDATES QUALIFICATIONS AND DISQUALIFICATIONS FOR ELECTION MEMBER OF PARLIAMENT QUALIFICATIONS AND DISQUALIFICATIONS FOR ELECTION MEMBER OF COUNTY ASSEMBLY 1) Are you eligible to be a candidate in accordance with the provisions of Kenyan 7

8 law as stated in the articles cited above? YES NO (If NO, provide details)... K. LIST OF REQUIREMENTS (Certified copies of all required documents below must be included when submitting the application form. Applications with missing or uncertified documents will not be accepted) 1) Original National Identification Card/Passport and 2 copies 2) 2 passport size coloured photographs 3) Ukweli Party Membership Card and/or Membership registration fee receipt 4) Letter of resignation from other political parties, if applicable 5) Confirmation of Party membership status (Office of the Registrar of Political Parties (ORPP) at 6) Ukweli Party nomination fees receipt 7) Voters Card and confirmation of registration with IEBC (SMS 22464) 8) Academic qualification certificates 9) Higher Education Loans Board (HELB) clearance certificate, if applicable 10) Ethics and Anti-Corruption Commission (EACC) Clearance Certificate 11) Kenya Revenue Authority (KRA) Tax Compliance Certificate 12) KRA PIN certificate 13) Credit Reference Bureau (CRB) certificate 14) Certificate of Good Conduct Signed by At. On this day of..20 8

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AGENCY APPLICATION (INDIVIDUAL)

AGENCY APPLICATION (INDIVIDUAL) To: Agency Department Date: AIG Asia Pacific Insurance Pte. Ltd. AIG Building 78 Shenton Way #07-16 Singapore 079120 From: Full Name as per NRIC/passport: Agency Name (if