UKWELI PARTY Nguvu Kwa Mwananchi APPLICATION FOR CONSIDERATION FOR PARTY LIST NOMINATION A. POSITION YOU ARE APPLYING FOR PARTY LIST NOMINATION

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1 UKWELI PARTY Nguvu Kwa Mwananchi APPLICATION FOR CONSIDERATION FOR PARTY LIST NOMINATION Note: This form must be filled by a Party member applying for acceptance and clearance by respective organs Ukweli Party to be considered for Party List Nomination for the 2017 General Elections. A. POSITION YOU ARE APPLYING FOR PARTY LIST NOMINATION I hereby apply to be considered for nomination to the Ukweli Party List for the position of Member of County Assembly (MCA) / Member of Parliament (MP) (please tick only the applicable position) should the Party qualify for slots after the 2017 general elections. COUNTY CONSTITUENCY WARD B. PERSONAL INFORMATION 1) FULL NAME:. 2) SEX: FEMALE MALE 3) DATE OF BIRTH: (DD/MM/YY):.. 4) ID/PASSPORT NUMBER:.. 5) VOTER REGISTRATION NUMBER:.... 6) 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: 1

2 By birth By registration By naturalization 3) List any other country/countries you are or have been a citizen: 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 Accomplishments F. MEMBERSHIP TO ORGANIZATIONS OR ASSOCIATIONS (List all the organizations or associations that you are or 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) From (year) PERIOD To (year) 2

3 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 nominee to the Party List, present a pitch of why you and state the category of special interest (disability, youth, marginalized, gender top-up, etc.). Please stick to the word limits for your statements.) 1) What is your main reason for applying for consideration for nomination to the Ukweli Party List? (150 words or less) 2) Why Ukweli and not any other party for you? (150 words or less) 3) What category of special interest (disability? youth? Gender top-up? marginalized? do you represent? Provide proof of your qualification under each category (350 words or less) 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

4 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 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, file a petition for bankruptcy, made a compromise or agreement with your creditors or gone out of business leaving debts outstanding? YES NO 10) If so in (9) above, have you been discharged? YES NO Not Applicable 4

5 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 ARTICLE 193 QUALIFICATION AND DISQUALIFICATIONS FOR ELECTION AS A MEMBER OF PARLIAMENT QUALIFICATIONS FOR ELECTION AS A MEMBER OF COUNTY ASSEMBLY THE ELECTIONS ACT 2011 ARTICLE 22 ARTICLE 23 ARTICLE 25 ARTICLE 26 QUALIFICATIONS FOR NOMINATION OF CANDIDATES QUALIFICATIONS AND DISQUALIFICATIONS FOR ELECTION AS A MEMBER OF PARLIAMENT QUALIFICATIONS AND DISQUALIFICATIONS FOR ELECTION AS A MEMBER OF COUNTY ASSEMBLY ADDITIONAL DISQUALIFICATIONS 1) Are you eligible to be a candidate in accordance with the provisions of Kenyan law as stated in the articles cited above? YES NO (If NO, provide details)... 5

6 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 4) Ukweli Party registration fee receipt 5) Letter of resignation from other political parties if applicable 6) Confirmation of Party membership status (Office of the Registrar of Political Parties (ORPP) at 7) Voters Card and confirmation of registration with IEBC (SMS 22464) 8) Higher Education Loans Board (HELB) clearance certificate 9) Ethics and Anti-Corruption Commission (EACC) Clearance Certificate 10) Kenya Revenue Authority (KRA) Tax Compliance Certificate 11) KRA PIN certificate 12) Credit Reference Bureau (CRB) certificate 13) Police Clearance Certificate 14) Academic qualification certificates 15) Ukweli Party nomination fees receipt 16) If applicant is under disability special category, medical proof is required L. PLEDGE OF COMMITMENT (For your application to be accepted for review, you must agree to, make and sign before a Commissioner of Oaths the Ukweli Party Pledge of Commitment below.) 1) NOMINATIONS PLEDGE OF COMMITMENT I.. of ID/Passport No. and... (Address) in the Republic of Kenya, applying to be considered for the Ukweli Party list for nomination as Member of Parliament /Member of County Assembly hereby solemnly swear and pledge as follows: 1. That I swear to respect, defend and safeguard the Constitution of Kenya and the Ukweli Party Constitution and all its policies. 2. That I shall be loyal to my country Kenya and the Party. 3. That I shall abide by the Party s motto of Power to the People / Nguvu Kwa Mwananchi and support the Party manifesto, programmes, values and principles and undertake to work for their realization. 6

7 4. That I shall abide by and promote all prescriptions by the Party on the conduct of free, fair, open and peaceful nominations and elections and that I will always act in fairness, respect and honour of fellow candidates and at no time will I conceive, promote or condone election malpractices; and shall comply fully with the Party s disciplinary process should I be found to have engaged in such malpractice 5. That I shall always stand for and defend the respect, promotion, protection and fulfillment of human rights and freedoms for all Kenyans. 6. That I shall accommodate criticism and plurality of ideas and observe principles and practices of open, good and accountable governance. 7. That I shall support free and fair elections within the Party and in all electoral areas and processes in Kenya. 8. That I shall openly oppose and never practice or condone tribalism, nepotism and I shall ensure that allocation of resources and services are done fairly and equitably, and jobs on merit, through open and auditable processes. 9. That I shall actively support and practice zero tolerance to corruption. 10. That I shall be transparent in all my business practices and transactions and never allow my personal interest to prevail over the public interest. 11. That I shall always defend and protect public property and that I shall at all times, through appropriate platforms, expose any misuse of public office, money, property and investments irrespective of who is involved in acts of misuse; 12. That I shall not practice or condone any forms and acts of discrimination, racism, sexism, xenophobia, prejudice, hatred, bigotry against any individual or group in Kenya and wherever I go; 13. That I swear this pledge on the understanding that I may be disqualified, or required to resign from leadership, or have my Party membership revoked if I violate this pledge of commitment. Signed by At. On this day of..20 Before me: Commissioner of Oaths 7