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Sponshorship Form

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ASSISTIVE TECHNOLOGY (AT) PROGRAM
SPONSORSHIP APPLICATION FORM

Prerequisites for AT Program Fellowship sponsorship: (tick all applicable fields)
  1. Area of work:
    • Working in a Government Hospital
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    • Committed to complete training and bonding in the area of bonding without defaulting
      		• chai->commit_to_complete == 'Yes') checked @endif value="Yes" id="flexCheckIndeterminate">
     
All applicants are required to attach the following documentation:
1. Completed AT Program sponsorship application & bonding forms; pre-authorization (during the application), release & bonding (once admitted)
2. Personal statement/reflective thinking summary about your passion for the course and desired impact post-training
3. Updated curriculum vitae
4. Copies of relevant academic certificates, licenses, and transcripts
5. Copy of national identity card/passport

NOTE: An application that does not comply with the above requirements will be regarded as incomplete.

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Postal Code {{ \App\User::find(auth()->user()->id)->applicant->postal_code }}
County {{ \App\County::find(\App\User::find(auth()->user()->id)->applicant->county_id)->name }}
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Affiliated Hospital/Institution
Number of years worked in named institution
Employment/Licence No:
Country regulatory body registration No
Current Job Group (if applicable):
Current Gross Monthly Salary in KSH:
Phone
Email Address
Sex:
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National ID No/Passport No: {{ \App\User::find(auth()->user()->id)->applicant->id_number }}
Date of Birth: {{ \App\User::find(auth()->user()->id)->applicant->date_of_birth }}
Date available to begin training:
Specialty or Sub-specialty applied for:
FUNDING: Tick appropriately
Do you have any other funding source to cover training costs either partially or fully?
chai->otherfunding == 'Yes') checked @endif disabled> chai->otherfunding == 'No') checked @endif value="No" disabled>
Indicate how much this other funding is and the source
Funding Amount
Source of funding
1. Emergency contact details (should we need to contact you urgently)
{{-- --}}
First Name
Surname
Title
Email:
Contact No:
2nd Contact No:
Relationship to applicant:
2. Emergency contact details (should we need to contact you urgently)
{{-- --}}
First Name
Surname
Title
Email:
Contact No:
2nd Contact No:
Relationship to applicant:
ACADEMIC HISTORY: TERTIARY EDUCATION
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UNIVERSITY/COLLEGE, COUNTRY: START DATE DATE OF COMPLETION DEGREE/DIPLOMA ATTAINED
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ANY ADDITIONAL QUALIFICATON ATTAINED
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TRAINING INSTITUTION, COUNTRY: START DATE DATE OF COMPLETION QUALIFICATION ATTAINED
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NAME OF RECOMMENDING SUPERVISOR AT THE HOSPITAL/INSTITUTION YOU ARE CURRENTLY STATIONED
Title:
Full Name:
Designation:
Phone No:
Email Address:
REFERENCES Please list 2 professional references
1.
Title:
Full Name:
Organization:
Phone No:
Email
Job Title

2.

Title:
Full Name:
Organization:
Phone No:
Email
Job Title
CURRENT AND PREVIOUS EMPLOYMENT (Note: Start with the most current)
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--}} @php $count++ @endphp @endforeach

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Organization: {{ $academic['emp_organization'] }} {{-- --}}
From: (month/year)
To:(month/year):
Job Title:
May we contact your previous employment for a reference?:
PRE-AUTHORIZATION FOR RELEASE

THE PREAUTHORIZING ENTITY
Statement of Release by Authorizing Officer:

I hereby confirm that upon successful admission to the course applied for,__________________________________________________________________ (fill in the name of preauthorizing entity) hereby commits to bond and release__________________________________________________________________ (fill in the name of the candidate) for Training in __________________________________________________________________(fill in the name of the course) for a period of________________________years from________________________ to________________________

Designation of authorizing officer:

Example: County employees should seek authorization from either County Executive Committee Member-Health, Chief Officer of Health, or County Secretary

Department of authorizing officer:

Date

After filling, download the form, have it signed and stamped by the Authorizing Officer, scan and then e-mail fully completed application to the chosen training institution.

DISCLAIMER AND SIGNATURE
I hereby, certify that I have provided accurate information in this application. If this application leads to a training sponsorship:
  • I understand that false or misleading information in my application or interview may result in my dismissal.
chai->dismissal_consent == 'Agree') checked @endif disabled>
chai->dismissal_consent == 'Disagree') checked @endif disabled class="form-check-input" type="radio" name="dismissal_consent" id="inlineRadio2" value="Disagree">
  • I understand that I am expected to complete the training and bonding without defaulting
chai->completion_consent == 'Agree') checked @endif disabled required class="form-check-input" type="radio" name="completion_consent" id="inlineRadio1" value="Agree" required>
chai->completion_consent == 'Disagree') checked @endif disabled required class="form-check-input" type="radio" name="completion_consent" id="inlineRadio2" value="Disagree">
AT Program is committed to maintaining the highest degree of ethical conduct and integrity. Direct or indirect canvassing will lead to automatic disqualification. In case of any demands for bribe, kickback, payment, gift, favours, or thing of value in connection with preauthorization/release and bonding write to DRstudentaffairs@kmtc.ac.ke

Signature of the Applicant:

Date