NATIONAL EMPOWERMENT NETWORK OF PEOPLE LIVING WITH HIV/AIDS IN KENYA
BOARD APPLICATION FORM.

APPLICANT DETAILS

NAME OF APPLICANT ___________________________________________SEX______________

POSTAL ADDRESS ________________________________________________________________

E- Mail _____________________________________ CELL PHONE _________________________

HIGHEST LEVEL OF EDUCATION ___________________________________________________

PROFESSION______________________________________________________________________

POSITION APPLYING FOR __________________________________________________________

SUPPORTING ORGANIZATION

ORGANIZATION NAME _____________________________________________________________

YEAR OF REGISTRATION WITH NEPHAK ____________________________________________

DATE OF LAST RENEWAL ________________________ NEPHAK REG. NO_________________

TYPE OF ORGANIZATION: NGO [____] CBO [____] FBO [____] NETWORK [____]

COUNTY:_________________ SUB-COUNTY:______________CONSTITUENCY______________

CONSENT BY CANDIDATE

I _____________________________________ do hereby confirm that I will adhere to NEPHAK Policies and Procedures and the NGOs Board Rules and Regulations if elected.

SIGNATURE. _______________________ I.D No._____________________ DATE ____________

RECIEVED BY NEPHAK SECRETARIAT
NAME DESIGNATION DATE SIGNATURE