NURSES WELFARE MEMBER'S REGISTRATION FORM
MANDATORY DOCUMENT REQUIRED
1.Applicant's ID/Passport copy
2.Applicants Passport size photo(WRITE NAME AT THE BACK)
3.Copy of next kin's ID /Passport/birth certificate in case of minors.
I hereby make an application for membership and agree to conform to the welfare by-laws, internal rules and regulations and Amendments thereof.

MEMBER DETAILS(USE BLOCK LETTERS)
Full Name*
First Name Last Name
Date of Birth
Month Day Year
Date
ID/Passport No.
ID
Postal Address
Postal Address
Street Address Line 2
City State / Province
Postal / Zip Code
Mobile Number*
Area Code Phone Number
Alternative Mobile Number
Area Code Phone Number
E-mail Address
example@example.com
APPLICANT'S JOB DETAILS
I hereby give consent for check off of money amounting to ..................... kes from my salary every month and the same deposited into the welfare account.
PAYROL
Consent for Deduction Sign
Clear
NEXT OF KIN DETAILS
Full Names ID/Passport/BirthCert No Phone No Relationship Allocations%
1.
2.
3.
4.
NOTE: Should any of the above details change.Please inform us immediately.
Applicants Signature
Clear
Date
Month Day Year
Date
For Official Use: Date of Admission
Month Day Year
Date of Admission
Membership Number:
Approved by:
Should be Empty:

NURSES WELFARE MEMBER'S REGISTRATION FORM