NOT FOR SALE

THINKERS.
DOERS.
LEADERS.

Application Form

M-PESA FOUNDATION ACADEMY APPLICATION FORM

THINKERS.
DOERS.
LEADERS.

THINKERS.
DOERS.
LEADERS.

be
be

KCPE
13

join

15

47
The

qualifying

disabilities

possible
available
better
Include
requirement.
artwork
Note

NOT AVAILABLE

However, remember

Do

absolutely
make available

be
be based on an independent application process
form 1

Only

Birth Certificate.
be considered.
be written
be enclosed

July 31st 2016.

submission.

July 31st will not be considered.

Application Forms
Receipt of Application
Only shortlisted candidates will be contacted.

Online
County

available
Offices
Sub-County
Retail
Local Churches and Mosques

Submission of Applications
Drop off/Submit your applications in one of the following ways:
mpesafoundationacademy.ac.ke

P.O. Box 7954 - 01000, Thika

Drop off
Thank you

look

Selection
be
A. Academic excellence
B. Leadership and entrepreneurship potential
C. Financial need
D. Responsible citizenship
E. Critical thinking skills
F. Problem solving skills

THINKERS.
DOERS.
LEADERS.

A.

APPLICANT PERSONAL DATA

First Name

Middle Name

Last Names
Date of Birth
(dd/mm/yyyy) (Attach

Gender

copy of Birth Certificate)

Do you have a
disability?

YES

NO

YES

NO

Male

Female

Please include
a copy of your
birth certificate.

If yes, please use the space below to give a brief

explanation. Attach copies of medical certificates.

If you have a disability,

what kind of support
would you need from
the Academy to
facilitate learning and
full participation?
Are you a citizen of
Kenya?
How did you find
out about M-PESA
Foundation Academy?

Newspapers

If no, what
is your
country of
citizenship?
Radio

TV

Social Media

Information Session

Other

If other, please explain

B.

ACADEMIC INFORMATION

Current Class
(e.g. 7)

Mark scored in
the last exam

......./500

Index Number
(MUST)

Please attach certified copies (stamped and signed by a school official) of your academic records/school
reports over the past three years. Do not send original copies as they will not be returned to you. If you do not
have these reports, please attach a clear and detailed explanation.
C.

SIBLING INFORMATION (BROTHERS AND SISTERS)

NAME

D.

MALE/FEMALE AGE

OCCUPATION

INSTITUTION/SCHOOL

EXTRA-CURRICULAR ACTIVITIES

Please list below all the activities that you have been involved in over the last two years. These could include
entrepreneurial activities, sports, arts, clubs, student leadership, conferences, among others (Attach copies of
certificates).
ACTIVITY

No. OF HOURS PER WEEK POSITION

M-PESA FOUNDATION ACADEMY APPLICATION FORM

NUMBER OF YEARS

FIRST NAME
E.

THINKERS.
DOERS.
LEADERS.

LAST NAME

PARENT or GUARDIAN INFORMATION

MOTHER OR GUARDIAN 1

FATHER OR GUARDIAN 2

First Name
Last Name
Married/divorced/separated/single
parent/widowed (Describe as
appropriate)
Alive or deceased? If deceased, give
date and attach death certificate
Country of citizenship
(If not Kenyan, state nationality)
National ID number (Attach a copy)
Where do you work?
Name of employer
Physical address of place of
employment (Town, estate, nearest
public landmark e.g. school, church,
mosque, hospital)
Income (Give details of salary per
month and attach a copy of pay slip)
Any other source of income,
including casual labour? Describe
and show the average monthly
income
Permanent physical home address
(Town, estate, nearest public
landmark by name and exact
location to the residence e.g. school,
church, mosque, hospital).
Is house owned, rented or employer
owned?
To be signed by parent or legal guardian where parents are deceased. Any documents that can prove legal
guardianship should be attached. Please sign below, accepting that you have read through this application in
detail and can confirm the accuracy of the information provided.
MOTHER OR GUARDIAN 1
First Name

Last Name

Signature

Date
(dd/mm/yyyy)

Telephone
Number
FATHER OR GUARDIAN 2
First Name

Last Name

Signature

Date
(dd/mm/yyyy)

Telephone
Number
M-PESA FOUNDATION ACADEMY APPLICATION FORM

FIRST NAME

LAST NAME

THINKERS.
DOERS.
LEADERS.

Why do you want to attend the M-PESA Foundation Academy? (Maximum 250 words)

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M-PESA FOUNDATION ACADEMY APPLICATION FORM

FIRST NAME

THINKERS.
DOERS.
LEADERS.

LAST NAME

What challenges have you faced in your educational journey and how have you overcome them?
(Maximum 350 words)
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M-PESA FOUNDATION ACADEMY APPLICATION FORM

FIRST NAME

LAST NAME

THINKERS.
DOERS.
LEADERS.

Of the extra-curricular activities you listed, which one do you enjoy most, and why? (Maximum 250 words)

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M-PESA FOUNDATION ACADEMY APPLICATION FORM

FIRST NAME

THINKERS.
DOERS.
LEADERS.

LAST NAME

Identify a challenge facing your community.

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What has been done (By the government, NGOs, or the community) to solve this challenge?
(Max 100 words)
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Considering the solutions above, what recommendations would you propose in overcoming the stated
challenge? (Max 150 words)
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M-PESA FOUNDATION ACADEMY APPLICATION FORM

FIRST NAME
G.

THINKERS.
DOERS.
LEADERS.

LAST NAME

PRINCIPAL OR HEAD OF CURRENT SCHOOL (TO BE FILLED OUT ONLY BY THE PRINCIPAL OR
HEAD OF SCHOOL THE APPLICANT IS CURRENTLY ATTENDING)

Last Name

First Name

Other Names
School Name
School Code Number
Office Phone

Mobile Phone

Permanent physical
address (State, town,
estate, nearest public
landmark to the school
e.g. church, mosque,
hospital)
Postal Address

County

Email Address
School Type (Mark all
that apply)

Public

Private

Religious

Boarding

Informal

Other

If other, please explain

Why would you recommend this applicant to the M-PESA Foundation Academy? Please comment on the
applicants conduct, special interests, talent, and/or disability status (Use the space below for your response
and sign on page 9).
NB: Kindly provide current and active postal code and address for the school, physical letters of acceptance
will be sent via the address provided.

M-PESA FOUNDATION ACADEMY APPLICATION FORM

FIRST NAME

THINKERS.
DOERS.
LEADERS.

LAST NAME

Please sign below, accepting that you have read through this application in detail and can confirm the accuracy
of the information provided.
Signature

Date
(dd/mm/yyyy)

M-PESA FOUNDATION ACADEMY APPLICATION FORM

THINKERS.
DOERS.
LEADERS.

H.

RECOMMENDATION BY DISTRICT OFFICER, CHIEF, PRIEST, PASTOR OR IMAM

Last Name

First Name

Other Names
Office Phone

Mobile Phone

Permanent physical
address (State, town,
estate, nearest public
landmark to the
school e.g. church,
mosque, hospital)
Postal Address

County

Email Address
Based on your knowledge and/or inquiries you have made, why would you recommend this applicant to
M-PESA Foundation Academy? (Use the space below for your response and sign on page 11)

10

M-PESA FOUNDATION ACADEMY APPLICATION FORM

THINKERS.
DOERS.
LEADERS.

Please sign below, accepting that you have read through this application in detail and can confirm the accuracy
of the information provided.
Signature and Rubber
Stamp

Date
(dd/mm/yyyy)

STUDENT'S DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge.
If this application leads to admission, I understand that false or misleading information in my application or
interview will result in immediate disqualification from the application process.
Signature
(Student)

Date
(dd/mm/yyyy)

Signature
(Parent/Guardian)

Date
(dd/mm/yyyy)

M-PESA FOUNDATION ACADEMY APPLICATION FORM

11

THINKERS.
DOERS.
LEADERS.

PARTNER PRIMARY SCHOOLS

PRIMARY SCHOOL

COUNTY

LOCATION

Chepnyorgin Primary School

Baringo

MARIGAT

Oldebes Primary School

Baringo

MOGOTIO

Masaba D.E.B Primary School, Bungoma

Bungoma

BUNGOMA

Kakoli Primary School

Busia

AMAGORO

Rumbiye Primary School

Busia

FUNYULA

St. Catherines Primary and Technical

Vocational Institute

Busia

BUTULA

S.A. Gategi Primary School

Embu

MBEERE SOUTH

Iftin Primary School

Garissa

WABERI

Nuraani Girls Primary School

Garissa

GARRISA

Emahungu Primary School

Kakamega

LURAMBI

Holy Cross Emalindi Primary School

Kakamega

KAKAMEGA

Kakamega Primary School, Special Unit

Kakamega

KAKAMEGA

Mwikhomo Primary School

Kakamega

KAKAMEGA

St. Peters Mumias Boys Primary School

Kakamega

MUMIAS

Chisaria Primary School

Kisii

NYAMIRA

Kuja Primary School for the Deaf

Kisumu

RONGO

Kiliko Primary School

Kitui

KITUI

Tanganyika Primary School

Kitui

KITUI

Mahiga Primary School

Laikipia

KINAMBA

Lamu Boys Primary School

Lamu

KISIWANI

Takaba Boarding Primary School

Mandera

TAKABA

Hermer Memorial Girls primary School

Marsabit

MARSABIT

Giampampo Primary School

Meru

CHUKA

Muchungucha Primary School

Muranga

MURANGA

Imara Primary School

Nairobi

MOMBASA ROAD

Kwa Njenga Primary School

Nairobi

MUKURU KWA NJENGA

Lavington Primary school

Nairobi

NAIROBI

Mukarara Primary School

Nairobi

DAGORETI

Kwa Njora Primary School

Nyandarua

NYAHURURU

Ndaragwa Primary School

Nyandarua

NDARAGWA, NYAHURURU

Nkondi Primary School

Tharaka Nithi

THARAKA

Machungwa Primary School

Trans Nzoia

KITALE

Testbourne Primary School

Trans Nzoia

KITALE

Lorengelup Primary School

Turkana

TURKANA

St. Augustine Boys Primary School

Turkana

LODWAR

Dasheg Primary School

Wajir

WAJIR

Fullow Primary School

Wajir

WAJIR

Wajir Girls Integrated Primary School

Wajir

WAJIR

Kaghmuu Primary School

West Pokot

KAPENGURIA

Kaptemow Primary School

West Pokot

KAPTEMOW

12

M-PESA FOUNDATION ACADEMY APPLICATION FORM

SAFARICOM RETAIL SHOPS LOCATIONS

THINKERS.
DOERS.
LEADERS.

NAIROBI EAST AND EASTERN REGION

NAME

LOCATION

SAFARICOM SHOP BURUBURU

Kenya National Library Services Building, Mumias Road, next to

St. James ACK Church

SAFARICOM SHOP EASTLEIGH

Nomad Palace Hotel, Ground Floor, General Waruinge Street, opposite

Eastleigh High School

SAFARICOM SHOP JKIA

Jomo Kenyatta International Airport (Lounges), Gate 11

SAFARICOM SHOP KIMATHI

Balfour Building, Ground Floor, Kimathi Street

SAFARICOM SHOP MOI AVENUE

Shankardass House, Ground Floor, Moi Avenue

SAFARICOM SHOP THIKA ROAD MALL

Thika Road Mall, off Kasarani Round About

SAFARICOM SHOP KITUI

Muli Mall, Town Centre, Kitui

SAFARICOM SHOP MACHAKOS

ABC Imani Plaza, Machakos Town

SAFARICOM SHOP GARISSA

Jihan Centre, Along Harambee Road, Garissa

NAIROBI WEST AND CENTRAL REGION

NAME

LOCATION

SAFARICOM SHOP BOMAS

Galleria Mall, Langata/Magadi Road Junction, opposite Bomas of Kenya

SAFARICOM SHOP I & M

I & M Towers, Ground Floor, Kenyatta Avenue

SAFARICOM SHOP JUNCTION

Junction Mall, Ground Floor

SAFARICOM SHOP NAKUMATT MEGA

Nakumatt Mega, Uhuru Highway

SAFARICOM SHOP SARIT CENTRE

Sarit Centre

SAFARICOM SHOP VILLAGE MARKET

Village Market Mall, Limuru Road

SAFARICOM SHOP SARIT PLATINUM

Sarit Centre

SAFARICOM SHOP THIKA

Haria House, Kwame Nkrumah Road, Thika

SAFARICOM SHOP EMBU

Kenyatta Highway, next to Equity Bank, Embu

SAFARICOM SHOP MAUA

Mikinuri Road (Main Street), next to KCB-Maua, Maua

SAFARICOM SHOP MERU

Ntima Building, Njuri Ncheke Street, Meru

SAFARICOM SHOP NYERI

Kangaru Building, Ground Floor, Kimathi Way, Nyeri Town

SAFARICOM SHOP NANYUKI

Nanyuki Mall, Nanyuki Highway

RIFT VALLEY AND WESTERN REGION

NAME

LOCATION

SAFARICOM SHOP BUNGOMA

Moghe Plaza, Bungoma

SAFARICOM SHOP JUBILEE

Jubilee Building, Ground Floor, Oginga Odinga Street, Kisumu

SAFARICOM SHOP KAKAMEGA

Conan Awori Street, next to Equatorial Commercial Bank, Kakamega

SAFARICOM SHOP KISII

Hospital Road, opposite Falcon Petrol Station, Kisii

SAFARICOM SHOP MEGA PLAZA

Mega Plaza, Ground floor, Oginga Odinga Road, Kisumu

SAFARICOM SHOP KISUMU

INTERNATIONAL AIRPORT

Kisumu International Airport

SAFARICOM SHOP ELDORET

Metro Towers, Ground Floor, Oginga Odinga Street, Eldoret

SAFARICOM SHOP KITALE

Former Raiya Supermarket, Kenyatta Street, Kitale

SAFARICOM SHOP NAIVASHA

Biashara Plaza, Ground Floor, Biashara Street, Naivasha

SAFARICOM SHOP NAKURU

Ereto Plaza, Mburu Gichua Road, Nakuru

SAFARICOM SHOP NAROK

Next to Co-operative Bank Building, Nairobi-Narok Highway, Narok

SAFARICOM SHOP KERICHO

Bus Park at Moi Gardens, opposite Kenya Commercial Bank, NakuruKisumu Highway

COAST REGION
NAME

LOCATION

SAFARICOM SHOP DIANI

Centre Point Mall

SAFARICOM SHOP DIGO ROAD

Digo Road

SAFARICOM SHOP MALINDI

TSS Building, Kenyatta Road, Malindi

SAFARICOM SHOP MOI INTERNATIONAL

AIRPORT

Moi International Airport, Terminal 1, Ground Floor, Mombasa

SAFARICOM SHOP REX HOUSE SHOP

Rex House, Ground Floor, Moi Avenue, Mombasa

SAFARICOM SHOP NYALI

Nakumatt Nyali, Malindi Road, Mombasa

M-PESA FOUNDATION ACADEMY APPLICATION FORM

13

THINKERS.
DOERS.
LEADERS.
THINKERS.

DOERS.
LEADERS.

M-PESA Foundation Academy

P.O. Box 7954 01000
Thika, Kenya
Telephone:
+254 (0) 703 200 000
Email:
admissions@mpesafoundationacademy.ac.ke
Website:
www.mpesafoundationacademy.ac.ke

14

M-PESA ACADEMY APPLICATION FORM