Membership Registration Form - Teachers Welfare Management System

Instructions: Please complete all sections with * marked as required. Write clearly in BLOCK LETTERS. Attach a recent passport-size photograph in the space provided.

1. PERSONAL INFORMATION

Title

Mr.

Mrs.

Miss

Dr.

Prof.

PASTE
PASSPORT
PHOTO
HERE

First Name *

Middle Name

Last Name *

AKA (Also Known As / Nickname)

Date of Birth *

Gender *

Male

Female

Number of Children

Marital Status *

Single

Married

Divorced

Widowed

Staff ID / Staff Number *

Home Town

Occupation / Role

Employer / School

Highest Qualification

SHS

Diploma

Degree

Postgraduate

2. CONTACT & ADDRESS

Phone *

Address *

City *

Region *

3. MEMBERSHIP INFORMATION

Membership Type *

Active

Associate

Retired

Long Distance

Date of Joining *

Previous Welfare Group / Association (if any)

Referee / Introducer Name

4. NEXT OF KIN & EMERGENCY CONTACT

Next of Kin Full Name *

Relationship *

Phone *

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Address

5. HEALTH & ADDITIONAL INFORMATION

Medical Conditions / Allergies (if any)

Special Needs / Disability

Skills / Talents (optional)

6. DECLARATION

I declare that the information provided is true and correct. I agree to abide by organization rules and regulations.

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Applicant's Signature

Date

FOR OFFICE USE ONLY

Member ID

Date Received

Approved By

Date Approved

Remarks

Signature/Stamp