EACC Chapter 6 Clearance Form: Self Declaration Form Free Download
Also see: Chapter 6 Requirements For TSC Promotions Interviews
LEADERSHIP AND INTEGRITY ACT, 2012 /KIFUNGU CHA SHERIA CHA UONGOZI NA UADILIFU, 2012
FIRST SCHEDULE (S.13) /TARATIBU YA KWANZA (S.13)
SELF-DECLARATION FORM / FOMU YA KUJITANGAZA
| 1. GENERAL INFORMATION / TAARIFA YA JUMLA | ||||||||
| Title / Cheo | Surname / Jina la
ukoo |
First Name / Jina
la Kwanza |
Middle Name /
Jina la Katikati |
Other Names / Majina
Mengine |
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| Mr/Mrs/Prof/ Miss/Ms/Dr
Bw/Bi/Prof/ Binti/Bibi/Dkt |
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| ID CARD No.
Na. ya Kitambulisho |
PASSPORT NO.
NA. ya PASIPOTI |
EXPIRY DATE OF PASSPORT
TAREHE YA MUDA WA PASIPOTI KUISHA |
PIN NO.
NA. ya PIN |
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| SEX (Tick)
JINSIA (Weka Alama)
Male Kiume
Female Kike |
Occupation:
Kazi:
E-Mail Address: Anwani ya Baruapepe:
Postal Address: PO Box Code: Anwani ya Posta: SL Posta: Msimbo:
Other Addresses: Anwani Nyingine: |
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| Telephone No.
Na. ya Simu |
Mobile No.
Na. ya Rununu |
Other Numbers
Nambari Nyingine |
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|
RESIDENCE MAKAZI |
ESTATE/TOWN/LOCATION
MTAA/MJI/LOKESHENI |
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| DISTRICT
WILAYA |
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| COUNTY
KAUNTI |
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| TOWN/CITY
MJI/JIJI |
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| COUNTRY
NCHI |
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| 2. BIRTH INFORMATION / TAARIFA YA KUZALIWA | ||||||||
| DATE OF BIRTH /TAREHE YA KUZALIWA | ||||||||
| BIRTH CERTIFICATE NO. / NA. YA CHETI CHA KUZALIWA | ||||||
| PLACE OF BIRTH / MAHALI PA KUZALIWA | ||||||
| DISTRICT OF BIRTH / WILAYA YA KUZALIWA | ||||||
| COUNTY OF BIRTH / KAUNTI YA KUZALIWA | ||||||
| COUNTRY OF BIRTH / NCHI YA KUZALIWA | ||||||
| 3. NATIONALITY /UTAIFA | ||||||
| Kenyan | Dual | |||||
| Mkenya | Kotekote
(Provide details ) (Toa maelezo ) |
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| 4. MARITAL STATUS / HALI YA NDOA
SINGLE MARRIED SEPARATED NINGALI SIJAOA/ SIJAOLEWA NIMEOA/NIMEOLEWA NIMETENGANA
DIVORCED WIDOWED NIMETALAKIANA NIMEFIWA |
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| IF MARRIED GIVE NAMES OF THE SPOUSE(S) (Surname, First Name, middle name, others)
KAMA UMEOA TOA MAJINA YA MUME/MKE(Wa) WAKO (Jina la ukoo, Jina la Kwanza, jina la kati, mengine) |
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| NATIONALITY OF SPOUSE
UTAIFA WA MKE/MUME |
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| NAME OF CHILDREN UNDER THE AGE OF 18 YEARS
JINA LA WATOTO WALIO CHINI YA UMRI WA MIAKA 18 |
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| 5. EDUCATIONAL QUALIFICATIONS / KUFUZU KWA KIELIMU | ||||||
| PRIMARY CERTIFICATE SECONDARY ‘A’ LEVEL
CHETI CHA MSINGI SHULE YA UPILI KIWANGO CHA ‘A’
DIPLOMA DEGREE MASTERS PHD STASHAHADA SHAHADA UZAMILI UZAMIFU
OTHERS VINGINE |
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| HIGHEST ACADEMIC QUALIFICATION OBTAINED
KUFUZU KWA JUU ZAIDI KWA KIAKADEMIA ULIKOPATA |
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| Qualification / Kufuzu | Institution / Taasisi | Year /Mwaka | |||||
| 6. LANGUAGE SPOKEN / LUGHA UNAZOZUNGUMZA | |||||||
| First Language
Lugha ya Kwanza |
Second Language
Lugha ya Pili |
Others
Nyingine |
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| 7. MEMBERSHIP OF PROFESSIONAL ORGANISATION(s) (If any)
UANACHAMA WA SHIRIKA(MA) YA KITAALAMU (Kama yapo) |
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| Name of Organization
Jina la Shirika |
Date of Admission
Tarehe ya Kuandikishwa |
Membership No.
Na. ya Uanachama |
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| 8. REASON(S) FOR DECLARATION / SABABU ZA KUJITANGAZA | |||||||
| Purpose for which declaration is required / Kusudio la kuhitajika kwa kujitangaza huku | |||||||
| Election Employment
Upigaji kura Kuajiriwa
Others (Specify) Nyingine (Bainisha) |
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| State office for which the declaration is being submitted
Ofisi ya serikali ambayo kujitangaza huku kunawasilishwa |
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| 9. MORAL AND ETHICAL QUESTIONS / MASWALI YA NIDHAMU NA KIMAADILI | |||||||
| Answers to the following questions are mandatory. If YES to any question you must provide additional information on a supplementary sheet.
Majibu kwa maswali yafuatayo ni lazima. Kama NDIYO katika swali lolote lazima utoe taarifa ya ziada kwenye karatasi nyingine. |
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| YES | NO | ||||||
| a) Have you ever engaged in any form of dishonesty in the conduct of public affairs
a) Umewahi kujihusisha na hali yoyote ya kutokuwa mwaminifu katika kazi zako na shughuli za umma |
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| b) Have you ever abused a public office?
b) Umewahi kutumia vibaya ofisi ya umma? |
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| c) Have you ever misrepresented information to the public?
c) Umewahi kuwakilisha kwa njia isiyofaataarifa kwa umma? |
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| d) Have you ever engaged in wrongful conduct whilst in the furtherance of
personal benefit? |
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| d) Umewahi kujihusisha katika tabia mbaya huku ukitaka kujinufaisha
kibinafsi? |
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| e) Have you ever misused public resources?
e) Umewahi kutumia vibaya rasilimali za umma? |
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| f) Have you ever discriminated against anyone of any grounds other than as provided for under the Constitution or any other law?
f) Umewahi kubagua yeyote kwa misingi yoyote mbali na vile ilivyoelezwa katika Katiba au sheria yoyote nyingine? |
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| g) Have you ever falsified official or personal records?
g) Je, umewahi kudanganya katika rekodi rasmi au za kibinafsi? |
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| h) Have you ever been debarred or removed from the Register of Members of your professional organization?
h) Umewahi kupigwa teke au kuondolewa kutoka kwenye Rejista ya Wanachama wa shirika lako la kitaalamu? |
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| i) Have you ever had any occupational or vocational license revoked and/or otherwise subjected to any other disciplinary action for cause in Kenya or any other country
i)Umewahi kujipata katika hali ya leseni yako ya kikazi au ya kiufundi kutupiliwa mbali na/au vinginevyo kuchukuliwa hatua nyingine ya kinidhamu katika nchi ya Kenya au nchi yoyote nyingine |
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| j) Have you ever dismissed from employment on account of lack of integrity?
j) Umewahi kufutwa kazi katika ajira kutokana na ukosefu wa uadilifu? |
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| k) If you have been a public officer, have you ever failed to declare your Income, Assets and Liabilities as required under the Public Officer Ethics Act, 2003?
k) Kama umewahi kuwa ofisa wa umma, umewahi kushindwa kutangaza Mapato yako, Mali na Gharama kama unavyohitajika katika Kifungu cha sheria cha Maadili ya Ofisa wa Umma, 2003? |
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| l) Have you ever been the subject of disciplinary or criminal proceedings for breach of the Public Officer Ethics Act, 2003 or a Code prescribed thereunder?
I) Umewahi kuwa mada katika taratibu za kinidhamu au kihalifu kwa kuvunja kifungu cha sheria cha Maadili ya Ofisa wa Umma 2003, au Msimbo ulioainishwa hapo chini? |
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| m) Have you ever been convicted of any offence and sentenced to serve imprisonment for a period of at least six months?
m) Umewahi kushtakiwa kwa kosa lolote na kuhukumiwa kifungo gerezani kwa kipindi kipatacho miezi sita? |
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| n) Have you ever had an application for a Certificate of Clearance or a Certificate of Good Conduct or for a visa or other document authorizing work in a public office denied and/or rejected for cause in Kenya or any
other country? |
| n) Umewahi kutuma ombi la Cheti cha kuondolewa Hatia au Cheti cha Kinidhamu au cha visa au nyaraka nyingine zinazoidhinisha kazi katika
ofisi ya umma na hivyo basi wewe kunyimwa na/ au kukataliwa kwa sababu yoyote nchini Kenya au nchi yoyote nyingine? |
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| 10. EMPLOYMENT INFORMATION / TAARIFA YA KUAJIRIWA | |||||
| NAME OF EMPLOYER | POSITION/RANK | DATE OF FIRST | DATE OF PRESENT | ||
| JINA LA MWAJIRI | CHEO/WADHIFA | APPOINTMENT | APPOINTMENT | ||
| TAREHE YA | TAREHE YA | ||||
| KUAJIRIWA KWA | KUAJIRIWA KWA | ||||
| KWANZA | SASA | ||||
| WORKSTATION | NATURE OF EMPLOYMENT | ||||
| KITUO CHA KAZI | (Constitutional/Elective/Permanent/Contractual/Other) | ||||
| AINA YA KUAJIRIWA | |||||
| (Kikatiba/Kuteuliwa/Kudumu/Kikandarasi/Nyingine) | |||||
OATH AND AFFIRMATION / KIAPO NA UTHIBITISHWAJI
I solemnly swear (or affirm) and certify, under penalty of false declaration under the Oaths and Statutory Declarations Act (Cap 15 of the Laws of Kenya), that all the foregoing statements in this declaration are true and correct to the best of my knowledge.
Ninaapa ya kwamba (ninathibitisha) na kuidhinisha, katika adhabu ya kujitangaza kwa uongo chini ya kifungu cha sheria cha Viapo na Kujitangaza Kisheria(Ibara 15 ya Sheria za Kenya), kwamba kauli zote zilizotajwa katika kujitangaza huku ni za kweli na sahihi kwa kadri ninavyojua.
Dated at / Mnamo tarehe ……………………………………………, this / kwenye……………………..
day of / siku hii ya ……………………………………….
SIGNATURE OF DECLARANT: ………………………………………………………………………………
SAINI YA ANAYEJITANGAZA:
SWORN/DECLARED BEFORE ME / ALIYELISHWA KIAPO/TANGAZWA MBELE YANGU
This / Mnamo ……………………….. day of / siku hii ya ……………………………, 20…………………………………………………………………………………………………………. ,
at / katika mahali hapa………………………………….
COMMISSIONER FOR OATH/MAGISTRATE
