Membership

Application Form

Member Name
Fund/Scheme Name

Section A - Member’s particulars

(please complete in full)

Member Name
KRA PIN Date of Birth dd mm yy yy

National ID No. Member’s Permanent

Residential Address
Permanent Address
P.O. Box Postal Code
Town County

Mobile No.
Home Work
E-mail Address
Employee/Staff No. Date of Employment dd mm yy yy

Basic Salary (p.a.) KShs

Gender Male Female Martial Status
Bank Name and Branch
Account No.

Section B - Declaration by the employee

I hereby declare that the above statements are true and correct to the best of my knowledge and belief.

Employee Signature: Date: dd mm yy yy

Section C - Declaration by the employer

Does the information provided by the Employee in the section above agree in all respects with your staff records?

Yes No Date the member joined the Scheme dd mm yy yy

Zamara Actuaries, Administrators & Consultants Limited O +254 (20) 4969 000
P.O. Box 52439 - 00200 Nairobi, 10th Floor, Landmark Plaza E vuna@zamara.co.ke
Argwings Kodhek Road, Opposite Nairobi Hospital W www.zamara.co.ke Actuaries | Administrators | Consultants | Insurance Brokers
Section B - Declaration by the employer (Cont.)
I hereby declare that the above statements are true and correct to the best of my knowledge and belief.

Authorised signature:

Name (Print)
Employer’s stamp

Designation

Contact number Date: dd mm yy yy

Copyright:
Copyright in this material is expressly reserved and this form and all attachments (where applicable) remains the exclusive property of Zamara
Actuaries, Administrators & Consultants Limited. This form and all attachments (where applicable) may not be copied, stored, retrieved or in any
way reproduced without the express written permission of Zamara Actuaries, Administrators & Consultants Limited. Breach of copyright is a serious
offence and can lead to litigation.