Citizen Registration

LinkedIn
This field is for validation purposes and should be left unchanged.
Name*
Prefix First Middle Last Suffix
Date of Birth
MM slash DD slash YYYY
Your Address in Kenya*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Your Kenyan Contact Number*
Your Address in Burundi ( Abroad )*
Street Address Address Line 2 City State / Province / Region Country
Your Local Contact Number*
Next of Kin Contact*
First Last
Relation*
e.g Parent
Phone*
Consent*
By sending this form and clicking the option “I AGREE”, Ihereby consent to the processing of my personal data which I hereby voluntarily provide. At the same time I declare that I am at least 18 years old and if not than I confirm that such consent has been expressed or given by the person who has the parental responsibility for me.
I agree

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