Mobile; 0700152177 OR 0752031300
Email: kisiipolytechnic@[Link]
kisiipolytechnic@[Link]
Website: [Link]
KNP/IMS/REG/F005
STUDENT’S INFORMATION DATA FORM
SECTION A
PERSONAL DETAILS
Student’s full name (use block letters)
Sir Name Middle Name First Name
Student’s Email Address (Must) ……………………………………………………………
National ID No------------------------Date of birth…………………. Gender………...............
Marital Status…………………………………………….. Tel. No……………………………….
Home County ……………………Sub County…………………District of birth…………….….
Last school/institution attended……………………………………………………………………
KCPE Index Number/Year ……………………………..………………………………………..
KCSE Index Number/Year ………………………………………………………………. ……..
Home address……………………………………………………………………………………..
Nearest Market…………………………………………………………………………………….
Area Chief: ………………………………Sub Chief: ……………………………………………
Contact Address: ……………………………………………………………….…………………
SPONSOR/PARENT/GUARDIAN DETAILS
Full Names………………………………………………………………………………………….
Tel No…………………………..Address …………………………………………………………
Relationship……………………………………………………………………………………….
1
In case of anything who should be contacted?
Name…………………………………………………………Tel No…………………………
Relationship……………………………………………………………………………………….
Name…………………………………………………………Tel No…………………………….
Relationship……………………………………………………………………………………….
.
SECTION B
OTHER INFORMATION
Tick the Most Appropriate Category Which You Belong.
.
Total Orphan Partial Orphan
Are You Presently Employed (Tick Appropriately) Yes No
Name of Employer: ………………………………………………………………………….
Address: ……………………………………………………………………………………….
Which are your hobbies/extracurricular activities?
………………………………….…………………………………………………………….
Special needs Yes/No. If yes, please specify (Blind, deaf, physically challenged, etc.)
………………………………………………………………………………………
(Pls attach disability card)
SECTION C
DECLARATION
1 (Names):……………………………………………………… ID NO:…………………………
I do declare that the information given above is true to the best of my knowledge
SIGNED………………………………………DATE…………………………………….
SECTION D
Note; The college will not be held responsible for any fraudulent information presented.
REGISTRY STAMP AND SIGNATURE
