| The Registrar,Estate Agents Registration Board,P.O. Box .............................Nairobi. | | Passport sizePhotograph☐ |
| A – GENERAL INFORMATION |
| Main name ..................................................... |
| (BLOCK CAPITALS) |
| Other names .............................................. |
| (BLOCK CAPITALS) |
| 2. Postal address ..................................................Residential address .............................................House No. ......................................... etc.Office physical address ................................................................................Office telephone No. ............................................ |
| 3. Date of birth ....................................... |
| 4. Nationality and citizenship .............................................. |
| (Please tick as applicable) |
| a) By birth ..................................... ☐b)By naturalization........................... ☐In each case please attach the following:(i)Your current passport size photo(ii) Copy of your identity card or birth certificate |
| B- EDUCATIONAL PARTICULARS |
| //Read carefully before completing all sectionsCopies of relevant leaving certificates, qualifications and testimonials must be attached in each case // |
| 1.Secondary schools attended:(a)(i) Name ........................................................(ii) Address ......................................................(iii) Period from ................................. to ...............(b)(i) Name ........................................................(ii) Address ......................................................(iii) Period from ................................. to ............... |
| 2.Colleges attended:(a)(i) Name ........................................................(ii) Address ......................................................(iii) Period from ................................. to ...............(b)(i) Name ........................................................(ii) Address ......................................................(iii) Period from ................................. to ............... |
| 3. Universities attended(a)(i) Name ........................................................(ii) Address ......................................................(iii) Period from ................................. to ...............(b)(i) Name ........................................................(ii) Address ......................................................(iii) Period from ................................. to ............... |
| Membership of professional institutions:(a)(i) Name ...........................................(ii) Date of registration ......................(b)(i) Name ...........................................(ii) Date of registration ...................... |
| C – EXPERIENCE AND EMPLOYMENT |
| (a)(i) Name of Employer ................................(ii) Address ....................................................................................(iii) Period from ............................. to .........................(b)(i) Name of Employer ................................(ii) Address ....................................................................................(iii) Period from ............................. to .........................(c)(i) Name of Employer ................................(ii) Address ....................................................................................(iii) Period from ............................. to ......................... |
| D – SELF EMPLOYMENT |
| (a) (i) Name of Company ..............................(ii) Address ..............................................................................................(iii) Period from .............................. to ..................... |
| E. PRACTICE IN ESTATE AGENCY(Please enclose a certified copy of certificate of registration in each case)1. LIMITED LIABILITY COMPANYName of Company ..............................Address ..............................................................................................Period from .............................. to .....................Names and addresses of the directors:1. ................................................2. ................................................3. ................................................4. ................................................2.PARTNERSHIPName .......................................................Address .................................................Period from ...................... to ....................Names and address of the partners:1. ................................................2. ................................................3. ................................................4. ................................................3.SOLE PROPRIETORSHIPName ......................................Address ..............................................Period from ................ to ............... |
| 1. LIMITED LIABILITY COMPANY(a)(i) Name ........................................................(ii) Address ......................................................(iii) Period from ................................. to ...............Names and addresses of the directors:1. .............................................................................2. ............................................................................3. ............................................................................4. ............................................................................ |
| 2.PARTNERSHIP(a)(i) Name ........................................................(ii) Address ................................................................................................................(iii) Period from ................................. to ...............Names and addresses of the directors:1. .............................................................................2. ............................................................................3. ............................................................................4. ............................................................................ |
| 3. SOLE PROPRIETORSHIP(a)(i) Name ........................................................(ii) Address ................................................................................................................(iii) Period from ................................. to ............... |
| F. OTHER BUSINESS PRACTICES(Give the names and addresses of all other business practices you are currently involved in) |
| 1. Name ........................................................Address ................................................................................................................Period from ................................. to ...............2.Name ........................................................Address ................................................................................................................Period from ................................. to ............... |
| G – OTHER GROUNDS TO SUPPORT YOUR APPLICATIONGive name and address of an official referee who knows your background history well, e.g. magistrate, chief or assistant chief of your area |
| 1. .............................................................................2. ............................................................................3. ............................................................................ |
| H. — BANKRUPTCY OR CONVICTION |
| Have you ever been declared bankrupt or convicted of any offence involving fraud or dishonesty? |
| Please tick as appropriateYes ☐ No. ☐ |
| I, enclose herewith banker’s cheque, money order payable o the Estate Agents Registration Board for Sh. 3,300, which I understand is not refundable. |
| H. — BANKRUPTCY OR CONVICTION |
| Have you ever been declared bankrupt or convicted of any offence involving fraud or dishonesty? Please tick as appropriate Yes ☐ No. ☐ |
| I, enclose herewith banker’s cheque, money order payable to the Estate Agents Registration Board for Sh. 3,300, which I understand is not refundable. |
| J. DECLARATIONI, declare that the foregoing statements are true and correct to the best of my knowledge and belief. I understand that any statement contained in this application which is found to be false shall invalidate this application. I have read the Estate Agents Act (Cap. 533) understood it and undertake to be bound by the Act and any amendments thereto or replacement thereof so long as I am a registered estate agent. |
| Applicant’s signature ...............................Date ..................................................Witness: Full name (Please print) .....................Address ......................................................................................................................................Telephone ........................................Signature .....................................FOR OFFICIAL USEApplication No. ...................................................Date acknowledged ...................................................Approved/rejected minute No. ...................................................Date notification sent ...................................................Gazette Notice No. ...................................................Certificate despatched ...................................................Certificate acknowledged ...................................................Registrar’s signature ..................................Date ........................................................Date received ..............................................Receipt No. .........................Date ...................Deferred Minute No. .....................................Registration No. .......................................Board member’s signature ..............................Date .........................................................Chairman’s signature ...................................Date ......................................................... |
