GNAT PROVIDENT FUND SCHEME MEMBERSHIP ENROLMENT FORM

DISTRICT CODE
REGION*
DISTRICT CODES - BRONG AHAFO
DISTRICT CODES - ASHANTI REGION
DISTRICT CODES - CENTRAL REGION
DISTRICT CODES - EASTERN REGION
DISTRICT CODES - GREATER ACCRA
DISTRICT CODES - NORTHERN REGION
DISTRICT CODES - UPPER EAST REGION
DISTRICT CODES - UPPER WEST REGION
DISTRICT CODES - VOLTA REGION
DISTRICT CODES - WESTERN REGION
SECTION 1
SCHEME NAME*
NAME OF SCHOOL:*
DISTRICT:*
DATE OF EMPLOYMENT

DayMonthYear
Date
DATE OF JOINING SCHEME

DayMonthYear
(Date of first deduction)
SECTION 2: PERSONAL DETAILS
NAME*

First NameLast Name
DATE OF BIRTH*

DayMonthYear
Date
GENDER*

MaleFemale
PLACE OF BIRTH:
EMAIL*
example@example.com
RANK*
Eg. Asst. Director (please indicate your position)
CURRENT STAFF NO:*
PREVIOUS STAFF NO.:
SOCIAL SECURITY NUMBER:*
PHONE NUMBER*
GHANA CARD NUMBER*
GHA-XXXXXXXXX-X
POSTAL ADDRESS:
BASIC SALARY (GH¢)*
Single Spine Monthly Salary
AMOUNT (GH¢)*
RATE (%)*
Contribution Rate
SECTION 3: BENEFICIARIES (IN EVENT OF MY DEATH, ANY BENEFITS ACCRUING TO ME UNDER THE FUND SHALL BE PAID TO MY BENEFICIARIES INDICATED BELOW)

NB: Percentage of benefit due to the beneficiary(ies) should add up to 100%*

	NAME OF BENEFICIARY	RELATIONSHIP	% OF BENEFIT DUE TO THE BENEFICIARY	DATE OF BIRTH	CONTACT
1
2
3
4
5
6
7
8
9
10

DECLARATION BY PARTICIPATING EMPLOYEE : I certify that the contents of the membership enrolment form are accurate.
Signature*

Clear
Date*

DayMonthYear
Date
Or Take Photo of Signature
Should be Empty:

SECTION 1