Form GHS.

3 - 001

APPLICATION NO: 79867038

PRINTOUT OF ON-LINE GENERAL HEALTH SYSTEM (GHS)

BENEFICIARY ENROLMENT REQUEST

Α. PERSONAL DETAILS
1. Applicant's Details:
(a) First Name: SAFIRA SUNAWARA
Last Name: ZAARA
(b) Date Of Birth: 04/06/2013
(c) Nationality: Bangladeshi
(d) Gender: F M
(e) Identification Document Type: RESIDENT CARD
Identification Document Number: 0581996346
Identification Document Expiry Date:
(f) Eligibility Category: 3CN - Family Member of Beneficiary

2. Family info:
(a) Marital Status: SINGLE
(b) Parents' Details
Father's Details
Father's Name: AKM MUJIBUL
Father's Last Name: HOQUE
Father's Identification Document Type: RESIDENT CARD Father's Identification Document Number: 0581978501
Mother's Details:
Mother's Name:
Mother's Last Name:
Mother's Identification Document Type: Mother's Identification Document Number:

Β. CONTACT AND ADDRESS DETAILS

1. Residence address:

Plataion 40, Flat No. 2

Postal code: 2027 Municipality/Community: NICOSIA
District: Strovolos Country: CYPRUS

2. Mailing Address:

Plataion 40, Flat No. 2

Postal code: 2027 Municipality/Community: NICOSIA

GHS Contact Centre

Tel.: 17000, calling from abroad: +357-22017000, Email: info@gesy.org.cy, Website: www.gesy.org.cy 1
 Form GHS.3 - 001

Po Box: - Po Box Post Code: 2027

District: Strovolos Country: CYPRUS

3. Telephone Number/Email:

Home Phone No: - Work Phone No: -

Mobile Phone No: +357 95992389
Email Address: mujibulhoque9@gmail.com
Next of Kin Name and Last Name: Sabikun Naher Next of Kin Phone No: 94495243
Communication Language: Greek English
Communication Channel: E-MAIL

C. DOCUMENTS WHICH MUST BE SUBMITTED TO HIO WITH THIS GHS ENROLMENT REQUEST
For each document submitted, please check the corresponding check box
1. Copy of Alien Registration Certificate (ARC)
2. Signed GHS enrolment form
3. Ordinary residence evidence
4. Copy of Identity Card or Alien Registration Certificate (ARC) of the family member who is a beneficiary
5. Proof of relationship with the beneficiary, one of the following:
• Birth Certificate
• Wedding Certificate
• Residence Card for non-EU Citizens family members of Union Citizen (MEU2 card)
• Other relation or proof of dependency document

Note: Holders of Immigration Permits under category F and Reg. 6(2) and their family members are requested to
submit additionally:
• electricity and water board bills covering the period of the last 12 months
• copies of their passports (all pages, including blanks)
• the «Declaration of entry & exit dates to the Republic of Cyprus» which can be found at the GHS website
• copy of last year's tax statement (if applicable)
• certificate of attendance from school/university in case the applicant is a dependent child

You may submit any other document you believe is applicable in your case for the purpose of HIO processing of
your GHS Beneficiary enrolment request. In such a case please describe below the relevant document (for example:
work permit)

Document Description:

D. DECLARATIONS
I hereby request enrolment to the GHS and declare that I have my ordinary residence in the areas controlled by the
government of the Republic. Also, I declare that all the information, certificates and supporting documents supplied
with this application, are true and correct and agree to submit any additional information that may be requested by
HIO for the purposes of handling my enrolment request. Furthermore, I undertake to immediately inform the HIO
of any changes to the information I have submitted within this request.

GHS Contact Centre

Tel.: 17000, calling from abroad: +357-22017000, Email: info@gesy.org.cy, Website: www.gesy.org.cy 2
 Form GHS.3 - 001

I am also informed that, according to Article 61 of the GHS Law, a person who wilfully provides false or inaccurate
information or particulars commits an offense and is liable to imprisonment or to a fine or to both.

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Applicant's Name and Last Name

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Date Signature

In case the enrolment request is submitted by a representative:

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Name and Last Name of Representative

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Date Identity Card No Signature

E. INSTRUCTIONS ON DOCUMENTS/EVIDENCE BEING SUBMITTED WITH THIS GHS

BENEFICIARY ENROLMENT REQUEST
Eligibility Documents:
You must submit the eligibility documents as indicated in section C above and any additional documents described
in this section if applicable for your case.

Additional eligibility evidence must be submitted in the following cases:

• Of dependent child over 21:
Student University Attendance Certificate OR Medical certificate of permanent disability AND
In the event that:
(a) the child is a dependent of the spouse of the beneficiary, then you must submit the marriage certificate or
certificate of civil union;
(b) the child is a dependent of divorced parents or orphaned by both parents then you must submit a copy
parenting court decision that states the person with whom the child lives with
(c) the dependent child is an orphan you must submit the death certificate of parent (s) from the Registry of the
Population and Migration Department
• Of child of a beneficiary:
In case where a birth certificate is not available please submit the adoption certificate (It is noted that the birth
/adoption certificate, must be submitted only if indicated in section C above)

Description of Ordinary Residence documents stated in section C

(You must submit one of the following documents as proof of your ordinary residence. The submitted documents
must be issued on the name of the applicant, unless the applicant is a minor child):
Electricity bills covering the period of the last three months
Home phone number telephone bills covering the period of the last three months
Water board bills covering the period of the last three months

GHS Contact Centre

Tel.: 17000, calling from abroad: +357-22017000, Email: info@gesy.org.cy, Website: www.gesy.org.cy 3
 Form GHS.3 - 001

Copy of title deed, or sale agreement, or valid rental contract (must submit all pages of the document)
Copy of last year's tax statement
Detailed (on a monthly basis) Social Insurance contributions statements for the current and last year from the
Social Insurance Services

When Ordinary Residence evidence is submitted in the name of spouse of the applicant,
you must additionally submit:
Mobile phone bills issued on the applicant's name covering a period of the last three months, on which the home
address must be clearly mentioned OR
Married Couple's declaration of cohabitation which is a solemn declaration stating that the couple lives together
and their home address is clearly mentioned. The declaration must be certified by the local authorities/community
leader of the area where they reside.

Translation/Authenticity of the documents

Public documents/certificates issued from third countries must have the apostille stamp or have an attestation, i.e.
a certification from the Cypriot Embassy in the country that issues the document.
Public documents/certificates issued from European countries that are NOT member-states must have the apostille
stamp or have an attestation. It is noted that the member-states of the EU are exempted from legalisation or
similar formality.
All documents must be translated in Greek by a sworn translator of the Republic of Cyprus, unless the authentic
public document that will be submitted is issued in Greek or English (applies for documents issued by all countries),
OR the standard multilingual document is attached to the authentic public document (applies only for documents
issued by EU countries).

All applicants must sign the GHS Enrolment Request and send it
with the supporting evidence/documents via post to the following address:

Health Insurance Organization,

P.O. Box 26765,
1641 Nicosia, Cyprus
The Health Insurance Organization may request any additional documents deemed as necessary
for the purpose of processing your enrolment request.
Applicants are requested to submit ALL the necessary documents/evidence within 30 days from the day of
submission of the electronic request, otherwise the Organization may proceed to reject their request. For
information regarding the status of their enrolment request the interested parties may communicate with
the GHS Contact Centre at 17000 or via email at info@gesy.org.cy

GHS Contact Centre

Tel.: 17000, calling from abroad: +357-22017000, Email: info@gesy.org.cy, Website: www.gesy.org.cy 4