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