APPLICANT INFORMATION

ASSISTIVE TECHNOLOGY (AT) PROGRAM SPONSORSHIP APPLICATION FORM

Prerequisites for AT Program Fellowship sponsorship: (tick all applicable fields)

Area of work:

Working in a Government Hospital
Committed to complete training and bonding in the area of bonding without defaulting

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.

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:
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> Yes

chai->otherfunding == 'No') checked @endif value="No" disabled> No

Do you have any other funding source to cover training costs either partially or fully?

chai->otherfunding == 'Yes') checked @endif disabled> Yes

chai->otherfunding == 'No') checked @endif value="No" disabled> No

indicate how much this other funding is and the source

Funding Amount

Source of funding

Emergency contact details (should we need to contact you urgently)

First Name

Surname

Title

1st Contact No:

2nd Contact No:

Email:

Relationship to applicant:

ACADEMIC HISTORY: TERTIARY EDUCATION

@foreach (App\User::find(auth()->user()->id)->academicHistory as $academic) @endforeach

UNIVERSITY/COLLEGE, COUNTRY:	START DATE	DATE OF COMPLETION	DEGREE/DIPLOMA ATTAINED

ANY ADDITIONAL QUALIFICATON ATTAINED

@foreach (App\User::find(auth()->user()->id)->academicQualification as $academic) @endforeach

TRAINING INSTITUTION, COUNTRY:	START DATE	DATE OF COMPLETION	QUALIFICATION ATTAINED

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:

Job Title

2. Title:

Full Name:

Organization:

Phone No:

Job Title

CURRENT AND PREVIOUS EMPLOYMENT (Note: Start with the most current)

@php $count=1 @endphp @foreach (App\User::find(auth()->user()->id)->employmentHistory as $academic)

{{ $count }}.

Organization:

From: (month/year):

To:(month/year):

Job Title:

May we contact your previous employment for a reference? @php echo $academic['emp_contact'] @endphp

Yes

Phone No:

Responsibilities:

{{ $academic['emp_responsibilities'] }}

@php $count++ @endphp @endforeach

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________________________

Authorizing Officer’s Name:

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:

Official Stamp of the preauthorizing 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> Agree

chai->dismissal_consent == 'Disagree') checked @endif disabled class="form-check-input" type="radio" name="dismissal_consent" id="inlineRadio2" value="Disagree"> 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> Agree

chai->completion_consent == 'Disagree') checked @endif disabled required class="form-check-input" type="radio" name="completion_consent" id="inlineRadio2" value="Disagree"> 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

Sponshorship Form

ASSISTIVE TECHNOLOGY (AT) PROGRAM SPONSORSHIP APPLICATION FORM

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

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THE PREAUTHORIZING ENTITY
Statement of Release by Authorizing Officer:

Designation of authorizing officer:

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.

Signature of the Applicant:

Date

Sponshorship Form

ASSISTIVE TECHNOLOGY (AT) PROGRAM SPONSORSHIP APPLICATION FORM

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

{{ $count }}.

THE PREAUTHORIZING ENTITY Statement of Release by Authorizing Officer:

Designation of authorizing officer:

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.

Signature of the Applicant:

Date

THE PREAUTHORIZING ENTITY
Statement of Release by Authorizing Officer: