D (Public Sector Enrolment Form)

NATIONAL PENSIONS ACT, 2008 (ACT 766)

CONTRIBUTOR STAFF ID

Form: - NPRA/PSW/CEF/2016

NAME OF MINISTRY:

MINISTRY CODE:

NAME OF CORPORATE TRUSTEE:

NAME OF SCHEME:

TYPE OF SCHEME:

PUBLIC SECTOR CONTRIBUTOR ENROLMENT FORM

CONTRIBUTOR’S NAME *

First

Middle

Last

PREVIOUS NAME / MAIDEN NAME *

First

Middle

Last

DATE OF BIRTH

AGE

SEX

Male
Female

NATIONALITY

MARITAL STATUS

PLACE OF BIRTH *

First

Middle

Last

COUNTRY OF BIRTH

PERMANENT ADDRESS

CURRENT CONTACT DETAILS

MOBILE PHONE NUMBER

FIXED LINE

E-MAIL ADDRESS *

DENTIFICATION DETAILS

Document ID

Passport
Driver’s Licence
Voter’s ID
National ID

ID NUMBER

SOCIAL SECURITY NUMBER

NAME OF FATHER *

NAME OF MOTHER *

FATHER’S ADDRESS

MOTHER’S ADDRESS

PREVIOUS EMPLOYER (IF ANY)

PREVIOUS CONTRIBUTOR ENROLLMENT NUMBER

NATURE OF EMPLOYMENT

NATURE OF INCOME

ANNUAL BASIC SALARY (GH¢)

MONTHLY BASIC SALARY (GH¢)

5% CONTRIBUTION (GH¢)

INSTITUTION’S NAME

INSTITUTION’S COD

INSTITUTION’S ADDRESS

INSTITUTION’S TEL. NUMBER

NOTE: All information should be written legibly and boldly in CAPITAL LETTERS.

BENEFICIARY NOMINATION

I HEREBY NOMINATE THE PERSON(S) BELOW AS MY DEPENDANTS TO RECEIVE DEATH AND SURVIVAL BENEFITS IN THE EVENT OF MY DEATH:

NAME OF BENEFICIARY

DATE OF BIRTH OF BENEFICIARY

CONTRIBUTOR ENROLLMENT NUMBER (IF ANY)

RELATIONS OF BENEFICARY TO CONTRIBUTOR

PERMANENT ADDRESS OF BENEFICARY

PERCENTAGE ALLOCATION TO BENEFICARY (To Total 100%)

DECLARATION:

I declare and certify that:-

1) I am not a member of any other similar scheme;
2) I am not in possession of another Contributor Enrollment Number;
3) the facts herein stated are accurate and true;
4) I am duly informed and to my full understanding that, I will be liable to prosecution for any false declaration herein or hereafter made to the Scheme.

FINGER PRINT IDENTIFICATION

LEFT THUMB PRINT

OTHER PRINTS WHERE THERE IS NO THUMB OR UNCLEAR FINGER PRINT MARKS

RIGHT THUMB PRINT

OTHER PRINTS WHERE THERE IS NO THUMB OR UNCLEAR FINGER PRINT MARKS

INDICATE WHICH FINGER

DATED:

SIGNATURE OR MARK OF CONTRIBUTOR (MARK):

DECLARATION BY ENROLLMENT OFFICER

I certify that this Contributor Enrollment Form was completed in my presence and under my supervision and that information herein contained is certified to be accurate and true.

NAME OF ENROLLMENT OFFICER

SIGNATURE

OFFICIAL STAMP OF SPONSORING EMPLOYER

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