Principal Member Registration

Principal Member Registration Form

Passport Picture *

Maximum file size: 3MB

Title *

Sex *

Male

Female

Surname *

First Name *

Other Names

Tel No.

Marital Status *

Date of Birth *

Are you registered under NHIS? *

Yes

If yes, NHIS No.

Postal Address *

Company Name *

Kindly select as many as apply to you – press and hold ctrl key to select multiple

Disclaimer

Declaration

By submitting this form, you confirm to the best of your knowledge and belief that the information you have provided is accurate and truthful. The information you have provided will be processed according to our privacy policy. Any false information provided on this form will result in the refusal of your application or termination of your membership and any payments made on your behalf shall be demanded.
I confirm that I have read and understood the terms above.

Sign *

Please type your name.

Principal Member Registration

Our Services

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