D (Public Sector Enrolment Form) NATIONAL PENSIONS ACT, 2008 (ACT 766) Please enable JavaScript in your browser to complete this form.CONTRIBUTOR STAFF ID Form: - NPRA/PSW/CEF/2016NAME OF MINISTRY:MINISTRY CODE:NAME OF CORPORATE TRUSTEE:NAME OF SCHEME:Public Sector EnrolmentTYPE OF SCHEME:PUBLIC SECTOR CONTRIBUTOR ENROLMENT FORMCONTRIBUTOR’S NAME *FirstMiddleLastPREVIOUS NAME / MAIDEN NAME *FirstMiddleLastDATE OF BIRTHAGESEXMaleFemaleNATIONALITYMARITAL STATUS PLACE OF BIRTH *FirstMiddleLastCOUNTRY OF BIRTH PERMANENT ADDRESS PERMANENT ADDRESS CURRENT CONTACT DETAILS MOBILE PHONE NUMBER FIXED LINEE-MAIL ADDRESS *DENTIFICATION DETAILS Document IDPassport Driver’s LicenceVoter’s ID National IDID NUMBERSOCIAL SECURITY NUMBERNAME OF FATHER *NAME OF MOTHER *FATHER’S ADDRESS MOTHER’S ADDRESS PREVIOUS EMPLOYER (IF ANY)PREVIOUS CONTRIBUTOR ENROLLMENT NUMBERNATURE OF EMPLOYMENT NATURE OF INCOMEANNUAL BASIC SALARY (GH¢) MONTHLY BASIC SALARY (GH¢)5% CONTRIBUTION (GH¢) INSTITUTION’S NAMEINSTITUTION’S CODINSTITUTION’S ADDRESS INSTITUTION’S TEL. NUMBERNOTE: 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 BENEFICIARYDATE 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 IDENTIFICATIONLEFT THUMB PRINTOTHER PRINTS WHERE THERE IS NO THUMB OR UNCLEAR FINGER PRINT MARKSRIGHT THUMB PRINTOTHER PRINTS WHERE THERE IS NO THUMB OR UNCLEAR FINGER PRINT MARKSINDICATE WHICH FINGERINDICATE WHICH FINGERDATED:SIGNATURE OR MARK OF CONTRIBUTOR (MARK):DECLARATION BY ENROLLMENT OFFICERI 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 OFFICERSIGNATURE OFFICIAL STAMP OF SPONSORING EMPLOYER Click or drag a file to this area to upload. Submit
