BPOMAS Application Form black 2

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SECTION 1 EMPLOYER DETAILSName of the Ministry / Department at which the applicant is employed PhoneSECTION 2 CHOICE OF OPTION Application form HIGH BENEFIT OPTIONSTANDARD BENEFIT OPTIONInitials SurnameFirst namesTelephone (work)Telephone (home)Fax NumberOccupationCell NoEmail addressPostal AddressNationalityID No. (locals) Pass No. (Non citizen)Attach copy of IDMonthly Salary (Yourself) PAttach copy of advice slipDate of BirthPayroll Spouse (if shown as a dependant below) P D D M M Y Y M F SECTION 4 BANK DETAILSBankBranchAccount Type: Current or savingsAccount Number(Attach Bank Statement) SECTION 5 FAMILY members TO BE COVEREDFirst Names & Surname(s)Birth DatesDDM MYYHusband Wife DaughterSonNat. ID / Passport Number(For persons over 16 years)IMPORTANT:PLEASE COMPLETE REVERSESignature of Member:Signature of Employer:Date of commencement of employmentDate of joining the schemePlease state pevious membership numberDate of previous membership: From to:Employer s date stamp:Administered by Associated Fund Administrators Botswana ( Pty) : AFA House Plot 61918 P O Box 1212 Gaborone Botswana Tele phone: (+267) 365 0555 (Call center) / 365 0500 (Reception) Fax: (+267) 395 1165Francistown Branch: SECTION 3 PRINCIPAL

Signature of Member: APPLICATION FORM (CONT.) SECTION 6 MEDICAL HISTORY Please give the name and address of the doctor or …

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