SERIAL NO.

NOMINATION APPLICATION DECLARATION FORM

POSITION BEING VIED FOR

I hereby make application to
Jubilee Party of Kenya to vie for position of

COUNTY CONSTITUENCY WARD

PERSONAL INFORMATION
This form should be filled in by the candidate when he/she is contesting in party nominations.
1. FULL NAME

2. CAMPAIGN NAME (IF ANY)

3. GENDER MALE FEMALE

4. DATE OF BIRTH

5. ID/PASSPORT NUMBER

6. VOTER REGISTRATION NUMBER

7. COUNTY CONSTITUENCY

WARD POLLING STATION

8.
TELEPHONE NUMBER

OTHER CONTACT

9. EMAIL ADDRESS

10. HAVE YOU EVER CHANGED YOUR NAME? YES NO

(IF YES) PREVIOUS NAME FROM (YEAR) TO (YEAR)

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 CITIZENSHIP

A. ARE YOU A KENYAN CITIZEN? YES NO

B. HOW DID YOU ACQUIRE YOUR CITIZENSHIP?

BY BIRTH
BY REGISTRATION
BY NATURALIZATION

C. LIST ANY OTHER COUNTRIES OF WHICH YOU ARE AND/OR HAVE BEEN A CITIZEN

PROFESSIONAL DESIGNATION

LIST ALL THE PROFESSIONAL DESIGNATIONS THAT YOU HAVE AND PROFESSIONAL
ASSOCIATIONS TO WHICH YOU BELONG (EXAMPLE- LAW SOCIETY OF KENYA, KENYA
INSTITUTE OF MANAGEMENT)

ASSOCIATION FROM (YEAR) TO (YEAR)

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 EDUCATION HISTORY

LIST YOUR EDUCATION HISTORY

QUALIFICATION
INSTITUTION FROM (YEAR) TO (YEAR)
OBTAINED

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 PROCEEDINGS BY REGULATORS
A. HAVE YOU BEEN SUBJECT TO DISCIPLINARY ACTIONS UNDERTAKEN BY ANY TRIBUNAL
OR ORGANIZATION? YES NO

(IF YES, PROVIDE DETAILS)

B. HAVE YOU EVER BEEN SUSPENDED, DISCHARGED OR ASKED TO RESIGN FROM ANY
EMPLOYMENT? YES NO

(IF YES, PROVIDE DETAILS)

C. DO YOU HAVE ANY OUTSTANDING LIABILITIES TO ANY TAXATION OR MONEY LENDING

AUTHORITY IN KENYA? YES NO

(IF YES, PROVIDE DETAILS)

OFFENCES UNDER THE LAW

A. HAVE YOU EVER BEEN CONVICTED OF ANY CRIME? YES NO
(IF YES, PROVIDE DETAILS)

B. HAS ANY PARTNERSHIP OR COMPANY YOU HAVE BEEN PART OF EVER BEEN CONVICTED
OF CRIMES? YES NO
(IF YES, PROVIDE DETAILS)

C. HAVE YOU EVER BEEN CONVICTED OF BREACH OF RULES AND REGULATIONS OR CODE
OF CONDUCT OF A PRIVATE ORGANIZATION OR NGO? YES NO
(IF YES, PROVIDE DETAILS)

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 BANKRUPTCY
A. HAVE YOU EVER BEEN DECLARED BANKRUPT, PRESENT A PETITION IN BANKRUPTCY,
MADE A COMPROMISE OR AGREEMENT WITH YOUR CREDITORS OR GONE OUT OF
BUSINESS LEAVING DEBTS OUTSTANDING? YES NO

(IF YES, PROVIDE DETAILS)

B. IF SO, HAVE YOU BEEN DISCHARGED? YES NO

FULL DISCLOSURE
A. ARE YOU AWARE OF ANY FACT NOT OTHERWISE DISCLOSED THAT; IF PUBLICLY KNOWN,
COULD CAUSE YOUR ELECTORAL CHANCES OR THE ELECTORAL CHANCES OF THE
JUBILEE PARTY TO BE MATERIALLY DISADVANTAGED OR COULD BE USED BY YOUR
OPPONENTS AGAINST YOU OR THE PARTY? YES NO

(IF YES,PROVIDE DETAILS)

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 QUALIFICATIONS TO BE A CANDIDATE
CONSTITUTION OF KENYA

CAP 7. -22 QUALIFICATIONS FOR NOMINATION OF CANDIDATES

CAP 7. -26 ADDITIONAL DISQUALIFICATION

ARTICLE 99 - QUALIFICATIONS AND DISQUALIFICATIONS FOR ELECTION AS

MEMBERS OF PARLIAMENT

ARTICLE 137 - QUALIFICATIONS AND DISQUALIFICATIONS FOR ELECTION AS

PRESIDENT

ARTICLE 193 - QUALIFICATIONS AND DISQUALIFICATIONS FOR ELECTION AS A

MEMBERS OF COUNTY ASSEMBLY

THE ELECTIONS ACT

ARTICLE 22 - QUALIFICATIONS FOR NOMINATION OF CANDIDATES

ARTICLE 23 - QUALIFICATIONS AND DISQUALIFICATIONS FOR ELECTION AS A

MEMBER OF PARLIAMENT

ARTICLE 24 - QUALIFICATIONS AND DISQUALIFICATIONS FOR ELECTION AS A

PRESIDENT

ARTICLE 25 - QUALIFICATIONS AND DISQUALIFICATIONS FOR ELECTION AS

MEMBERS OF COUNTY ASSEMBLY

ARTICLE 26 - ADDITIONAL QUALIFICATIONS

YES NO

ARE YOU ELIGIBLE TO BE A CANDIDATE IN ACCORDANCE WITH THE PROVISIONS OF THE LAW

AS STATED IN THE ARTICLES ABOVE?

(IF NO, PROVIDE DETAILS)

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 LIST OF REQUIREMENTS
1. TWO PASSPORT SIZE PHOTOGRAPHS

2. ORIGINAL IDENTIFICATION CARD

3. REGISTERED AS A VOTER WITH IEBC (SMS 22464)

4. HIGHER EDUCATION LOANS BOARD (HELB) CERTIFICATE

5. CERTIFICATE OF GOOD CONDUCT

6. ETHICS AND ANTI-CORRUPTION COMMISSION (EACC) CERTIFICATE

7. KENYA REVENUE AUTHORITY (KRA) CERTIFICATE

8. CREDIT REFERENCE BUREAU (CRB) CERTIFICATE

9. ACADEMIC CERTIFICATES

10. PIN CERTIFICATE

11. JUBILEE MEMBERSHIP CARD

12. RESIGNATION LETTER FROM OTHER PARTIES

13. NOMINATION FEE RECEIPT

14. REGISTRATION FEE RECEIPT

15. CHECK PARTY MEMBERSHIP STATUS (RPP) www.orpp.or.ke

Account Name: Jubilee Party

Account No: 0180270840079

Bank: Equity Bank

Branch: NHIF Branch

Certified copied of each of the above documents should be included when submitting the
application form. No applications will be accepted without ALL the documentation required.

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 PART 1. LEADERSHIP AND INTEGRITY
1. I HEREBY DECLARE THAT AS THE CANDIDATE OF JUBILEE PARTY, AND, IF
ELECTED, AS THE REPRESENTATIVE OF BOTH IN PUBLIC LIFE, IN OFFICIAL LIFE
AND IN ASSOCIATION WITH OTHER PERSONS, I WILL

- CONDUCT MY CAMPAIGNS PEACEFULLY, DISCOURAGE ALL ACTS OF VIOLENCE

BY ANY INDIVIDUAL OR GROUP; WHETHER IN MY SUPPORT OR OTHERWISE
- NOT ENGAGE IN TALK OR ACTION THAT WILL INCITE THE PUBLIC NEGATIVELY
AND/OR INFLAME TRIBAL TENSIONS
- EMPLOY OBJECTIVITY AND IMPARTIALITY IN DECISION MAKING
- ENSURE THAT DECISIONS ARE NOT INFLUENCED BY NEPOTISM, OTHER
IMPROPER MOTIVES OR CORRUPT PRACTICES
- PERFORM SELFLESS SERVICE BASED SOLELY ON PUBLIC INTEREST
- EXERCISE HONESTY IN THE EXECUTION OF PUBLIC DUTIES
- DECLARE ANY PERSONAL INTEREST THAT MAY CONFLICT WITH PUBLIC DUTIES
- BE ACCOUNTABLE TO THE PUBLIC FOR MY DECISION AND ACTIONS
- EXERCISE DISCIPLINE AND COMMITMENT IN SERVICE TO THE PEOPLE
- AVOID ANY CONFLICT BETWEEN PERSONAL INTERESTS AND PUBLIC OR
OFFICIAL DUTIES
- AVOID COMPROMISING ANY OFFICIAL INTEREST IN FAVOUR OF A PERSONAL
INTEREST
- AVOID DEMEANING THE OFFICE OR ANY POSITION HELD

I HEREBY DECLARE THAT

- ANY GIFT OR DONATION RECEIVED AS STATE OFFICER ON A PUBLIC OR OFFICIAL

OCCASION SHALL BE DELIVERED TO THE STATE UNLESS EXEMPTED UNDER AN ACT OF
PARLIAMENT
- I DO NOT AND SHALL NOT MAINTAIN A BANK ACCOUNT OUTSIDE KENYA EXCEPT IN
ACCORDANCE WITH AN ACT OF PARLIAMENT
- I SHALL NOT SEEK OR ACCEPT A PERSONAL LOAD OR BENEFIT IN CIRCUMSTANCES
THAT COMPROMISE THE INTEGRITY OF THE POSITION HELD
- AS A FULL-TIME STATE OFFICER, I SHALL NOT PRACTICE IN ANY OTHER GAINFUL
EMPLOYMENT

APPLICANT NAME

SIGNATURE DATE / /

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 PART II. LEADERSHIP AND THE PARTY

1. I HEREBY AGREE

- TO ABIDE BY THE LAWS OF KENYA, PARTICULARLY THE KENYAN CONSTITUTION, THE

POLITICAL PARTIES ACT, THE ELECTIONS ACT, THE LEADERSHIP AND INTEGRITY ACT,
THE POLITICAL PARTY CODE OF CONDUCT AND THE ELECTION CODE OF CONDUCT
- TO ACTIVELY SUPPORT AND BE PROUD OF THE PARTY CONSTITUTION,
PARTY RULES AND REGULATIONS AND THE CODE OF THE PARTY CONSTITUTION, PARTY
RULES AND REGULATIONS AND THE CODE OF CONDUCT OF THE PARTY
- TO SUPPORT THE VISION AND MISSION OF THE PARTY OUTLINED IN THE PARTY POLICY
DOCUMENTS
- TO PROMOTE THE PARTYS POLICIES AND ACT AS AN AMBASSADOR OF THE PARTY
- TO SUBMIT ALL DISPUTES TO THE PARTY INTERNAL DISPUTE RESOLUTION
MECHANISMS

ASPIRANT NAME

SIGNATURE DATE / /

PAGE 99