NOMINATION APPLICATION DECLARATION FORM

Transcription

1 SERIAL NO. NOMINATION APPLICATION DECLARATION FORM POSITION BEING VIED FOR I Jubilee Party of Kenya to vie for position of hereby make application to COUNTY CONSTITUENCY WARD PERSONAL INFORMATION This form should be filled in by the candidate when he/she is contesting in party nominations FULL NAME CAMPAIGN NAME (IF ANY) 3. GENDER MALE FEMALE DATE OF BIRTH ID/PASSPORT NUMBER VOTER REGISTRATION NUMBER COUNTY WARD TELEPHONE NUMBER OTHER CONTACT ADDRESS CONSTITUENCY POLLING STATION 10. HAVE YOU EVER CHANGED YOUR NAME? YES NO (IF YES) PREVIOUS NAME FROM (YEAR) TO (YEAR) PAGE 1

2 CITIZENSHIP ARE YOU A KENYAN CITIZEN? YES NO B. HOW DID YOU ACQUIRE YOUR CITIZENSHIP? BY BIRTH BY REGISTRATION BY NATURALIZATION C. LIST ANY OTHER COUNTRIES OF WHICH YOU ARE AND/OR HAVE BEEN A CITIZEN PROFESSIONAL DESIGNATION LIST ALL THE PROFESSIONAL DESIGNATIONS THAT YOU HAVE AND PROFESSIONAL ASSOCIATIONS TO WHICH YOU BELONG (EXAMPLE- LAW SOCIETY OF KENYA, KENYA INSTITUTE OF MANAGEMENT) ASSOCIATION FROM (YEAR) TO (YEAR) PAGE 2

3 EDUCATION HISTORY LIST YOUR EDUCATION HISTORY INSTITUTION QUALIFICATION OBTAINED FROM (YEAR) TO (YEAR) PAGE 3

4 PROCEEDINGS BY REGULATORS HAVE YOU BEEN SUBJECT TO DISCIPLINARY ACTIONS UNDERTAKEN BY ANY TRIBUNAL OR ORGANIZATION? YES NO B. HAVE YOU EVER BEEN SUSPENDED, DISCHARGED OR ASKED TO RESIGN FROM ANY EMPLOYMENT? YES NO C. DO YOU HAVE ANY OUTSTANDING LIABILITIES TO ANY TAXATION OR MONEY LENDING AUTHORITY IN KENYA? YES NO OFFENCES UNDER THE LAW HAVE YOU EVER BEEN CONVICTED OF ANY CRIME? YES NO B. HAS ANY PARTNERSHIP OR COMPANY YOU HAVE BEEN PART OF EVER BEEN CONVICTED OF CRIMES? YES NO C. HAVE YOU EVER BEEN CONVICTED OF BREACH OF RULES AND REGULATIONS OR CODE OF CONDUCT OF A PRIVATE ORGANIZATION OR NGO? YES NO PAGE 4

5 BANKRUPTCY HAVE YOU EVER BEEN DECLARED BANKRUPT, PRESENT A PETITION IN BANKRUPTCY, MADE A COMPROMISE OR AGREEMENT WITH YOUR CREDITORS OR GONE OUT OF BUSINESS LEAVING DEBTS OUTSTANDING? YES NO B. IF SO, HAVE YOU BEEN DISCHARGED? YES NO FULL DISCLOSURE ARE YOU AWARE OF ANY FACT NOT OTHERWISE DISCLOSED THAT; IF PUBLICLY KNOWN, COULD CAUSE YOUR ELECTORAL CHANCES OR THE ELECTORAL CHANCES OF THE JUBILEE PARTY TO BE MATERIALLY DISADVANTAGED OR COULD BE USED BY YOUR OPPONENTS AGAINST YOU OR THE PARTY? YES NO (IF YES,PROVIDE DETAILS) PAGE 5

6 QUALIFICATIONS TO BE A CANDIDATE CONSTITUTION OF KENYA CAP QUALIFICATIONS FOR NOMINATION OF CANDIDATES CAP ADDITIONAL DISQUALIFICATION ARTICLE 99 - QUALIFICATIONS AND DISQUALIFICATIONS FOR ELECTION AS MEMBERS OF PARLIAMENT ARTICLE QUALIFICATIONS AND DISQUALIFICATIONS FOR ELECTION AS PRESIDENT ARTICLE QUALIFICATIONS AND DISQUALIFICATIONS FOR ELECTION AS A MEMBERS OF COUNTY ASSEMBLY THE ELECTIONS ACT ARTICLE 22 - ARTICLE 23 - QUALIFICATIONS FOR NOMINATION OF CANDIDATES QUALIFICATIONS AND DISQUALIFICATIONS FOR ELECTION AS A MEMBER OF PARLIAMENT ARTICLE 24 - QUALIFICATIONS AND DISQUALIFICATIONS FOR ELECTION AS A PRESIDENT ARTICLE 25 - QUALIFICATIONS AND DISQUALIFICATIONS FOR ELECTION AS MEMBERS OF COUNTY ASSEMBLY ARTICLE 26 - ADDITIONAL QUALIFICATIONS YES NO ARE YOU ELIGIBLE TO BE A CANDIDATE IN ACCORDANCE WITH THE PROVISIONS OF THE LAW AS STATED IN THE ARTICLES ABOVE? (IF NO, PROVIDE DETAILS) PAGE 6

7 LIST OF REQUIREMENTS TWO PASSPORT SIZE PHOTOGRAPHS ORIGINAL IDENTIFICATION CARD REGISTERED AS A VOTER WITH IEBC (SMS 22464) HIGHER EDUCATION LOANS BOARD (HELB) CERTIFICATE CERTIFICATE OF GOOD CONDUCT ETHICS AND ANTI-CORRUPTION COMMISSION (EACC) CERTIFICATE KENYA REVENUE AUTHORITY (KRA) CERTIFICATE CREDIT REFERENCE BUREAU (CRB) CERTIFICATE ACADEMIC CERTIFICATES PIN CERTIFICATE JUBILEE MEMBERSHIP CARD RESIGNATION LETTER FROM OTHER PARTIES NOMINATION FEE RECEIPT REGISTRATION FEE RECEIPT CHECK PARTY MEMBERSHIP STATUS (RPP) Account Name: Jubilee Party Account No: Bank: Equity Bank Branch: NHIF Branch Certified copied of each of the above documents should be included when submitting the application form. No applications will be accepted without ALL the documentation required. PAGE 7

8 PART 1. LEADERSHIP AND INTEGRITY 1. I HEREBY DECLARE THAT AS THE CANDIDATE OF JUBILEE PARTY, AND, IF ELECTED, AS THE REPRESENTATIVE OF BOTH IN PUBLIC LIFE, IN OFFICIAL LIFE AND IN ASSOCIATION WITH OTHER PERSONS, I WILL - CONDUCT MY CAMPAIGNS PEACEFULLY, DISCOURAGE ALL ACTS OF VIOLENCE BY ANY INDIVIDUAL OR GROUP; WHETHER IN MY SUPPORT OR OTHERWISE - NOT ENGAGE IN TALK OR ACTION THAT WILL INCITE THE PUBLIC NEGATIVELY AND/OR INFLAME TRIBAL TENSIONS - EMPLOY OBJECTIVITY AND IMPARTIALITY IN DECISION MAKING - ENSURE THAT DECISIONS ARE NOT INFLUENCED BY NEPOTISM, OTHER IMPROPER MOTIVES OR CORRUPT PRACTICES - PERFORM SELFLESS SERVICE BASED SOLELY ON PUBLIC INTEREST - EXERCISE HONESTY IN THE EXECUTION OF PUBLIC DUTIES - DECLARE ANY PERSONAL INTEREST THAT MAY CONFLICT WITH PUBLIC DUTIES - BE ACCOUNTABLE TO THE PUBLIC FOR MY DECISION AND ACTIONS - EXERCISE DISCIPLINE AND COMMITMENT IN SERVICE TO THE PEOPLE - AVOID ANY CONFLICT BETWEEN PERSONAL INTERESTS AND PUBLIC OR OFFICIAL DUTIES - AVOID COMPROMISING ANY OFFICIAL INTEREST IN FAVOUR OF A PERSONAL INTEREST - AVOID DEMEANING THE OFFICE OR ANY POSITION HELD I HEREBY DECLARE THAT - ANY GIFT OR DONATION RECEIVED AS STATE OFFICER ON A PUBLIC OR OFFICIAL OCCASION SHALL BE DELIVERED TO THE STATE UNLESS EXEMPTED UNDER AN ACT OF PARLIAMENT - I DO NOT AND SHALL NOT MAINTAIN A BANK ACCOUNT OUTSIDE KENYA EXCEPT IN ACCORDANCE WITH AN ACT OF PARLIAMENT - I SHALL NOT SEEK OR ACCEPT A PERSONAL LOAD OR BENEFIT IN CIRCUMSTANCES THAT COMPROMISE THE INTEGRITY OF THE POSITION HELD - AS A FULL-TIME STATE OFFICER, I SHALL NOT PRACTICE IN ANY OTHER GAINFUL EMPLOYMENT APPLICANT NAME SIGNATURE DATE / / PAGE 8

9 PART II. LEADERSHIP AND THE PARTY 1. I HEREBY AGREE - TO ABIDE BY THE LAWS OF KENYA, PARTICULARLY THE KENYAN CONSTITUTION, THE POLITICAL PARTIES ACT, THE ELECTIONS ACT, THE LEADERSHIP AND INTEGRITY ACT, THE POLITICAL PARTY CODE OF CONDUCT AND THE ELECTION CODE OF CONDUCT - TO ACTIVELY SUPPORT AND BE PROUD OF THE PARTY CONSTITUTION, PARTY RULES AND REGULATIONS AND THE CODE OF THE PARTY CONSTITUTION, PARTY RULES AND REGULATIONS AND THE CODE OF CONDUCT OF THE PARTY - TO SUPPORT THE VISION AND MISSION OF THE PARTY OUTLINED IN THE PARTY POLICY DOCUMENTS - TO PROMOTE THE PARTY S POLICIES AND ACT AS AN AMBASSADOR OF THE PARTY - TO SUBMIT ALL DISPUTES TO THE PARTY INTERNAL DISPUTE RESOLUTION MECHANISMS ASPIRANT NAME SIGNATURE DATE / / PAGE 9