Membership enrolment form

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Membership enrolment form

Scheme and employer information

Please complete in full.

Scheme name *

Type of scheme * Tier 2 Tier 3

Employer’s name * Employer’s enrolment number * Employer’s address * Branch / site / location * Employer’s telephone number *

Member’s particulars

Please complete in full.

Title Mr. Miss Ms. Mrs. Dr. Prof. Hon. Rev.

Surname First name * Other names * Identification number

Type of identification * Passport Driver’s license Voter’s ID Ghana Card

Marital status

Gender Male Female

Date of birth Age Place of birth (town) Country of birth District Region Residential address Postal address Work Cell Email * Father’s name * Mother’s name * Nature of employment *

Employment type Permanent Temporary

Company employee number SSNIT number Date joined fund Date of employment Monthly basic / pensionable salary

Fingerprint identification (optional)

Left thumb print Right thumb print Date Signature of the contributor

Member’s declaration

I hereby confirm that the information provided above are correct. I am duly informed and to my full understanding that I will be liable for prosecution for any false declaration herein or hereafter made to the Scheme.

Member’s name * Date Member’s signature

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Leader in People Benefits in Africa. NBC Ghana Trust provides independent pensions trust, retirement planning, and employee benefits with no ownership ties to any life assurer or asset manager.

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No. 2 Gowa Rd,
Emerald House,
Roman Ridge, Accra
info@nbcghanatrust.com
+233 307 022257/8

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