Optometrist Welfare Fund User registration form SurnameOther Names *OAK reg. No *National ID no. *Date of BirthGenderMaleFemaleEmployerEmployment address (incl. postcode)Permanent address (incl. postcode)Email *Phone no. *SurnameOther Names *National ID no *Date of birthMobile phone number *Name of the parent *Date of BirthID Number *GenderMaleFemaleName of the parent *Date of BirthID Number *GenderMaleFemaleName of the childDate of BirthAttach Birth CertificateChoose FileNo file chosenDelete uploaded fileName of the childDate of BirthAttach Birth CertificateChoose FileNo file chosenDelete uploaded fileName of the childDate of BirthAttach Birth CertificateChoose FileNo file chosenDelete uploaded fileName of the childDate of BirthAttach Birth CertificateChoose FileNo file chosenDelete uploaded fileContributor Passport PhotoChoose FileNo file chosenDelete uploaded fileSpouse Passport PhotoChoose FileNo file chosenDelete uploaded fileParent Passport PhotoChoose FileNo file chosenDelete uploaded fileParent Passport PhotoChoose FileNo file chosenDelete uploaded fileChild 1 Passport PhotoChoose FileNo file chosenDelete uploaded fileChild 2 Passport PhotoChoose FileNo file chosenDelete uploaded fileChild 3 Passport PhotoChoose FileNo file chosenDelete uploaded fileChild 4 Passport PhotoChoose FileNo file chosenDelete uploaded fileI acknowledge that I have read the Optometrists welfare fund constitution, rules and the bylaws and I agree to abide by them.Name of the contributorSignDateNote For the processing of your registration pay non-refundable admission fee of KSH 500. Monthly subscription fee is KSH 300 paid to OPTOMETRIST WELFARE FUND ACCOUNT NUMBER: 1297338715 KCB MOI AVENUE. MPESA PAY BILL NO.: 522522 The fund covers up to 4 children (proof needed). An additional child attracts additional fee of KSH 100 per child. Attach copies of national ID of the persons listed or copy of birth certificate for persons under the age of 18. SUBMITSave as Draft Logout
