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    EACC Chapter 6 Clearance Form: Self Declaration Form Free Download

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    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

    Get PDF Copy here

    SELF-DECLARATION-FORM

    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
    Mr/Mrs/Prof/ Miss/Ms/Dr

    Bw/Bi/Prof/ Binti/Bibi/Dkt

    		        
    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
           
    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:
    Telephone No.

    Na. ya Simu

    		 Mobile No.

    Na. ya Rununu

    		 Other Numbers

    Nambari Nyingine
     

     

     

     

    RESIDENCE

    MAKAZI

    		 ESTATE/TOWN/LOCATION

    MTAA/MJI/LOKESHENI

    		  
    DISTRICT

    WILAYA

    		  
    COUNTY

    KAUNTI

    		  
    TOWN/CITY

    MJI/JIJI

    		  
    COUNTRY

    NCHI

    		  
    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                                                                   )
    4. MARITAL STATUS / HALI YA NDOA

     

    SINGLE                                                MARRIED                                SEPARATED

    NINGALI SIJAOA/ SIJAOLEWA             NIMEOA/NIMEOLEWA                                                            NIMETENGANA

     

    DIVORCED                                           WIDOWED

    NIMETALAKIANA                                NIMEFIWA
    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)
    NATIONALITY OF SPOUSE

    UTAIFA WA MKE/MUME

    		  
    NAME OF CHILDREN UNDER THE AGE OF 18 YEARS

    JINA LA WATOTO WALIO CHINI YA UMRI WA MIAKA 18
    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

     

    HIGHEST ACADEMIC QUALIFICATION OBTAINED

    KUFUZU KWA JUU ZAIDI KWA KIAKADEMIA ULIKOPATA
    Qualification / Kufuzu Institution / Taasisi Year /Mwaka
         
    6. LANGUAGE SPOKEN / LUGHA UNAZOZUNGUMZA
    First Language

    Lugha ya Kwanza

    		 Second Language

    Lugha ya Pili

    		 Others

    Nyingine
         
    7. MEMBERSHIP OF PROFESSIONAL ORGANISATION(s) (If any)

    UANACHAMA WA SHIRIKA(MA) YA KITAALAMU (Kama yapo)
    Name of Organization

    Jina la Shirika

    		 Date of Admission

    Tarehe ya Kuandikishwa

    		 Membership No.

    Na. ya Uanachama
         
         
         
    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)
    State office for which the declaration is being submitted

    Ofisi ya serikali ambayo kujitangaza huku kunawasilishwa

    		  
    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.
      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

    		    
    b) Have you ever abused a public office?

    b) Umewahi kutumia vibaya ofisi ya umma?

    		    
    c) Have you ever misrepresented information to the public?

    c) Umewahi kuwakilisha kwa njia isiyofaataarifa kwa umma?

    		    
    d) Have you ever engaged in wrongful conduct whilst in the furtherance of

    personal benefit?

    		    

     

    d) Umewahi kujihusisha katika tabia mbaya huku ukitaka kujinufaisha

    kibinafsi?

    		    
    e) Have you ever misused public resources?

    e) Umewahi kutumia vibaya rasilimali za umma?

    		    
    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?

    		    
    g) Have you ever falsified official or personal records?

    g) Je, umewahi kudanganya katika rekodi rasmi au za kibinafsi?

    		    
    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?

    		    
    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

    		    
    j) Have you ever dismissed from employment on account of lack of integrity?

    j) Umewahi kufutwa kazi katika ajira kutokana na ukosefu wa uadilifu?

    		    
    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?

    		    
    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?

    		    
    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?

    		    
    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?

    		    
    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

    KAMISHNA WA KIAPO/ HAKIMU

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