Name ………………………………………

Sex ………………………………………….

Son/daughter/wife of …………………
………………………………………………

Year of birth ………………………………

Address ……………………………………

………………………………………………

………………………………………………

Dispensary ………………………………

Local Office……………………………….

Prepared by

Signature or thumb-impression

of the employee

Identification marks

Photograph of the Insured Person

Employment changes

Date         Code No.           Date                  Code No.