• Sun. Oct 13th, 2024

EACC Chapter 6 Clearance Form: Self Declaration Form Free Download

ByCitizen digital

Oct 9, 2024

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

Leave a Reply

Your email address will not be published. Required fields are marked *