GOCARD & GOCLUB Registration

GOCARD & GOCLUB REGISTRATION
Title

Mr.Mrs.Dr.Prof.Ms.
Full Name (To appear on the GOCARD)*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

DayMonthYear
ID Type*
ID Number*
This will be verified. Enter without characters like -,#,$ or space
Address (Postal)*

Example : P.O. Box 1234

Example AN- Accra North

CityRegion

Postal / Zip Code
Address (Residential)*

Street Address

Street Address line 2

CityRegion

Postal / Zip Code
Tel. No. 1 ( Mobile)*
Please enter a valid phone number.
Tel. No. 2 ( Mobile)
Please enter a valid phone number.
Email Address*
Please enter a valid email address
Name of Receiver
Who can receive your card on your behalf?
Tel. No
Please enter a valid phone number.
Please tick one of the following options:
Notifications*

SMSEmail
Pick-up Options*

SelfDelivery
Statements*

PrintEmail
Register as a member of GOClub*

YesNo
LIFE INSURANCE DETAILS

Free Life insurance is one of the benefits of joining the GOClub. Please provide the following details in case of any insurance claim:
Is your beneficiary older than 18 years?*

YesNo
Beneficiary Name*

First NameLast Name
Do you want to use the previous address provided for LIFE INSURANCE CLAIMS?*

YesProvide Beneficiary contact details
Address (Postal)*

Example : P.O. Box 1234

Example AN- Accra North

CityRegion

Postal / Zip Code
Address (Residential)*

Street Address

Street Address line 2

CityRegion

Postal / Zip Code
BENEFICIARY DETAILS

In case the beneficiary is less than 18 years of age,it is required by law to have a trustee appointed.
Name of Trustee*

First NameLast Name
Phone Number of Trustee*
Please enter a valid phone number.
Address (Postal)*

Example: P.O. Box 1234

Example: AN Accra-North

CityState / Province

Postal / Zip Code
Email Address*
Please enter a valid email address
Special G O O D N E S S awaits YOU!
JOIN A SOCIAL GROUP OR FAMILY
End RegistrationSpecial GOODNESS
JOIN NOW!*

FAMILYSOCIAL Group
Name of Social Group*
Please provide the details of the executive members
1st Executive *

First NameLast Name
Phone Number (Mobile)*
Please enter a valid phone number.
2nd Executive

First NameLast Name
Phone Number (Mobile)
Please enter a valid phone number.
Name of Family*
Name of Primary Card Holder*

First NameLast Name
Card Number*
Enter 16-Digits on your Card
Please verify that you are human*
Should be Empty:

GOCARD & GOCLUB REGISTRATION