0000982-Employment Application Form - CPSB 2

NOT FOR SALE KCPSB/01 (Revised 2017)
Folio No:.......................
COUNTY GOVERNMENT OF KERICHO
COUNTY PUBLIC SERVICE BOARD
APPLICATION FOR EMPLOYMENT FORM
Please complete this form in BLOCK letters. Submit it to the Secretary, County
Public Service Board, P.O.BOX 1376, 20200 KERICHO, or apply on-line via the
Public Service Board Job Application Portal; www.psbkericho.org .
Vacancy Applied For
Attach copies of certificates, testimonials, a copy of coloured passport size photo, copy
of ID card and clearance certificates (KRA, CID, HELB and EACC).All parts of this form
must be filled.
PART 1
1. Vacancy applied for
Vacancy/Post: …………………..................................Vacancy No:………………..........

Department...................................................................……………..............
Terms of Service (As per advert) Permanent & pensionable Contract
Temporary
2. Personal Details
Name of Applicant: ……………………………….................Title………………………….....

Surname First Name Other name(s) (Prof/Dr/Mr/Mrs/Miss/Ms/Rev/etc)
Date of Birth:…………………………….…………….………..…. Gender: (M/F)...................
PWD (Yes/No)...................... Nature of Disability........................ Reg No....................

Nationality:……………………………….....................................Ethnicity........................
ID No/Passport No:.......................Employment/Personal No:....................................
Address:……………………………......................................Postal Code:…………............
Home County ...................................Home Sub-County............................................
Home Ward..........................Location................................. Ward of Birth.................
Marital Status:................................................Telephone:………................................
Mobile No................:………………............E-mail address:…………..............................
Alternative contact person:……….………………....................Telephone:………………....
3. Applicants in the Public Service only
Ministry/Department/County/Other Public Institutions:……………...........................
Station:……….............Present Substantive Post................................ Job group:….…
Effective date ...… Upgrading (if applicable) Post:……………….Effective date:…………
Terms of Service: Permanent & Pensionable Contract Temporary
4. Applicants NOT in Public Service Only

4. Applicants in Private/NGO/ Other Sectors
Current employer:…………….....................................................................................
Position held:…….............................................................Effective date:…................
Station ......................................................Gross Salary (monthly) Ksh.……………...
5.Other Details.
5. Other Details
Indicate the language(s) you are proficient in…………………………………………………
Have you ever been convicted of any criminal offence or a subject of probation order?
Yes No If yes, give details:...................................................................................
Have you ever been dismissed or otherwise removed from employment? Yes No
If Yes, state reason (s) for dismissal/removal………………...........................................
Effective date.............................................................................................................
Have you ever been interviewed by Kericho County Public Service Board before?
Yes No
If Yes, State the post:...................………………………………………………......................
and interview date:………………………….………………………….....................................
(Declaring the above information will not necessarily debar an applicant from
employment in Public Service. Each case will be considered on its own merit)
6 Academic/Professional/Technical Qualifications (Starting with the Highest)
6 Acad /Professional/Technical Qualifications (Starting with the Highest)
Year University/ Award/Atta Courses Subject/ Class
College/ inment e.g. (e.g. Option /Grade
Institution Degree, PhD,MSc, (Econ,Maths,
/School Diploma, BA) Finance etc)
Certificate
From To
7. Other Relevant Courses and Training/Registration /Membership to

Professional Bodies/Institution. Duration of Course in Weeks/ Months /Years.
Year Duration- In Institution/ Courses

From To weeks/Months College
/Yrs
8. Employment Details (Starting with the most recent)
Year Employer’s Name Position/ Rank/ Job

From To Designation Group/Gross
Monthly
Salary(Kshs)
(a). Briefly state your current duties, responsibilities and assignments

……………………………………………………………………………………............................
……………………………………………………………………………………………………………
………..……………….…..…..……..................................................................................
……………………………………………………………………………………………………………
……….…………………..…………….…….......................................................................
(b). Please give details of your abilities, skills and experience which you consider are
relevant to the position applied for. The information may include an outline of your
most recent achievements and your reasons for applying………………………………....
………….…………………………………………………………………......................................
..................................................................................................................................
…………………………………………………………………………………………………………….
………….…………………………………..…......................................................................
9. Personal References
11. Personal References
The names of distinguished persons should not be used unless they really know you
well. The names of relatives or staff members of the Kericho Public Service Board
should also not be used.
(i). Full Name:…………………………………………Title……………………………..…...........
Address:………………………………………………………………………………………….........
Telephone No:………………Mobile No…………………… E-mail address:……..................
Occupation:………………………………Title .......................…………………………………..
Period for which he/she has known you:………………………………………..…………......

(ii). Full Name:…………………………………………… Title………………………….…...........
Address:………………………………………………………………………………….……............
Telephone No:…………………… Mobile No ……….....………. E-mail .............................
Occupation:………………………………………… Title…………………………….................
Period for which /he/she has known you:…………………………………………………......
10. Declaration:
I hereby certify to the best of my knowledge that the particulars given on this form
are correct and I understand that any incorrect information may lead to
disqualification/legal action.
Date: …………………….....................................…....................................................
Signature of the Applicant
PART 2
11. Recommendation/Comments by Head of Department

1 Head of Department/Supervisor Recommendation (PSC 2A) Form
To be completed by immediate supervisor where applicable
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
Name of Supervisor .................................................. Department.............................
Designation ...............................................................Signature.......................... .....
Date...........................................................Official Stamp:.........................................
12. For Official Use Only
Received By: Name: .................................... Signature...................... Date:...............
Countersigned by Applicant.............................................. Date................................

0000982-Employment Application Form - CPSB 2

Uploaded by

0000982-Employment Application Form - CPSB 2

Uploaded by

NOT FOR SALE KCPSB/01 (Revised 2017)

COUNTY GOVERNMENT OF KERICHO

COUNTY PUBLIC SERVICE BOARD

APPLICATION FOR EMPLOYMENT FORM

Vacancy/Post: …………………..................................Vacancy No:………………..........

Name of Applicant: ……………………………….................Title………………………….....

Date of Birth:…………………………….…………….………..…. Gender: (M/F)...................

PWD (Yes/No)...................... Nature of Disability........................ Reg No....................

Station:……….............Present Substantive Post................................ Job group:….…

Effective date ...… Upgrading (if applicable) Post:……………….Effective date:…………

Terms of Service: Permanent & Pensionable Contract Temporary

4. Applicants NOT in Public Service Only

Position held:…….............................................................Effective date:…................

Station ......................................................Gross Salary (monthly) Ksh.……………...

Yes No If yes, give details:...................................................................................

If Yes, state reason (s) for dismissal/removal………………...........................................

If Yes, State the post:...................………………………………………………......................

and interview date:………………………….………………………….....................................

7. Other Relevant Courses and Training/Registration /Membership to

Year Duration- In Institution/ Courses

Year Employer’s Name Position/ Rank/ Job

(a). Briefly state your current duties, responsibilities and assignments

(i). Full Name:…………………………………………Title……………………………..…...........

Telephone No:………………Mobile No…………………… E-mail address:……..................

Period for which he/she has known you:………………………………………..…………......

Telephone No:…………………… Mobile No ……….....………. E-mail .............................

Period for which /he/she has known you:…………………………………………………......

11. Recommendation/Comments by Head of Department

Designation ...............................................................Signature.......................... .....

12. For Official Use Only

Received By: Name: .................................... Signature...................... Date:...............

Countersigned by Applicant.............................................. Date................................

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