MOONLIGHT CYBER – KISIWA BRANCH
Complete HELB Application Information Form (Student Fill-In Form)
SECTION A: PERSONAL DETAILS
Full Name (as per ID): ______________________________
Gender: ☐ Male ☐ Female
Date of Birth: ____ / ____ / ______
National ID Number: _____________________
HELB Portal Email Address: _______________________________Email Password: __________
Phone Number (must be registered under ID): _____________________
County of Birth: ____________________
Sub-County of Birth: ____________________
Constituency: ____________________
Ward: ____________________
Nationality: ☐ Kenyan ☐ Other
Disability: ☐ Yes ☐ No
If yes, type of disability: ____________________
SECTION B: RESIDENCE DETAILS
Current Residence County: ____________________
Sub-county: ____________________
Ward: ____________________
Location: ____________________
Sub-location: ____________________
Village/Estate: ____________________
Nearest School/Church/Mosque/Chief’s Office: ____________________
House Number (if any): ____________________
SECTION C: EDUCATION BACKGROUND
Primary School
School Name: __________________________
County: ____________________
Year Completed: ______
KCPE Index Number: ____________________
Secondary School
School Name: __________________________
County: ____________________
Year Completed: ______
KCSE Index Number: ____________________
Mean Grade: ______
ADDITIONAL
Did you apply for KUCCPS?
If yes which institution were you place? _______________
If yes which course were placed in? ___________________________________
Level of the course you were placed in Diploma____ Certificate________ Artisan
SECTION D: UNIVERSITY/COLLEGE DETAILS
Institution Name: __________________________
Campus: ____________________
Admission Number: ____________________
Mode of Study: ☐ Regular ☐ Self-sponsored ☐ Parallel ☐ Distance
Type: ☐ University ☐ TVET ☐ College
Course Name: __________________________
Level of Study: ☐ Certificate ☐ Diploma ☐ Degree
Year of Study: ☐ 1st ☐ 2nd ☐ 3rd ☐ 4th
Semester: ☐ 1st ☐ 2nd ☐ 3rd
Expected Graduation Year: ______
Expected Graduation Month: _______________
SECTION E: PARENT/GUARDIAN DETAILS
Father’s Details
Full Name: ____________________
ID Number: ____________________
Phone Number: ____________________
Occupation: ____________________
Is he alive? ☐ Yes ☐ No
If deceased, year of death: ______
Mother’s Details
Full Name: ____________________
ID Number: ____________________
Phone Number: ____________________
Occupation: ____________________
Is she alive? ☐ Yes ☐ No
If deceased, year of death: ______
Guardian (if applicable)
Full Name: ____________________
Relationship: ____________________
ID Number: ____________________
Phone Number: ____________________
Occupation: ____________________
SECTION F: FAMILY INCOME DETAILS
Tick any source of family income and provide estimated monthly income:
Income Source Tick Amount per Month (KES)
Farming ☐ _______________________
Employed parent ☐ _______________________
Income Source Tick Amount per Month (KES)
Business ☐ _______________________
Pension ☐ _______________________
Rental income ☐ _______________________
Support from relatives ☐ _______________________
Others: ____________ ☐ _______________________
Total Monthly Household Income: ____________________ KES
SECTION G: SIBLINGS / DEPENDENTS
List the names and levels of education of your siblings or children dependent on your parents/guardian.
Full Name Age School/College Level Year/Class
SECTION H: BANKING DETAILS
Bank Name: __________________________
Branch: ____________________
Bank Code (e.g., 01 for Co-op): ___________
Account Number (Student’s Name Only): __________________________
Account Type: ☐ Savings ☐ Current
SECTION I: HELB LOAN REQUEST
Loan Type: ☐ First Time Application ☐ Subsequent
Loan Amount Requested: ☐ 37,000 ☐ 50,000 ☐ Other: ___________
Are you receiving any other bursary/scholarship? ☐ Yes ☐ No
If yes, specify name and amount: __________________________
SECTION J: DOCUMENTS TO ATTACH (Photocopies)
☐ National ID (Front and Back)
☐ KCSE Result Slip or Certificate
☐ Admission Letter
☐ Student ID or Institution ID Confirmation
☐ Parent(s)/Guardian ID Copy
☐ Bank ATM Card (showing Account Name & Number)
☐ Passport Photo (2 recent, color)
☐ Birth Certificate
☐ Death Certificate (if orphaned)
☐ Copy of NHIF Card (optional)
SECTION K: DECLARATION
I confirm that all the information I have provided is true and complete. I allow my cyber operator to use
these details for HELB loan application on my behalf.
Signature: _____________________
Date: ____ / ____ / ______
