EACC Chapter 6 Clearance Form: Self Declaration Form Free PDF Download

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EACC Chapter 6 Clearance Form: Self Declaration Form Free Download

TABLE OF CONTENTS

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

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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.