Page 52 - Nomination Rules

SELF-DECLARATION FORM
1. General Information
………………………… …………………………… ……………………
(Surname) (First Name) (Middle Name)
(Other Names)

National ID No. / Passport No.: ……………………...………………….

Passport Expiry Date: ……………………………………………..………

Party Membership No.: ………………………………………

Sex: (tick where appropriate) Male ( ) Female ( ) Intersex ( )

Occupation: ..................................................Mobile Number:………….

Email Address: ..................................................................................

Nationality: Kenyan ( ) Dual Citizen ( ) (provide details).................
......................................... ....................................................

2. Declaration

I declare that I have fulfilled all requirements under the laws relating to elections, the party constitution and
nomination rules including –

(a) meeting obligations imposed by the political party on its members including payment of requisite fees;

(b) producing valid educational certificates as and when requested; and

(c) being of good moral standing in society;

3. Oath and Affirmation
I solemnly swear (or affirm) and certify, under penalty of false declaration under the Oaths and Statutory
Declarations Act (Cap 15 of the Laws of Kenya), that all the statements in this declaration are true and
correct to the best of my knowledge.

Dated this …………….day of ……………………… 20 ………

Signature of Declarant ……………….........................................................

Sworn/Declared Before Me

This ........................ day of…............................................., 20 ..................,
At .......................................................................
Commissioner for Oath/Magistrate

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