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1 of 5

01. Personal Information

Full name

Date of birth

Gender

Marital status

Nationality

Phone number

2 of 5

02. Employment Information?

Public Service Ministry/Department

IPPIS Number

Grade Level

Designation

Work Location

Valid ID Card

Latest payslip (Showing IPPIS Number)

3 of 5

03. Residential Address

Address Line 1

Address Line 2

City/Town

State

Zip Code

4 of 5

04. Next of Kin

Full name of Nominee

Relationship to Applicant

NOK Phone Number

NOK Email Address

NOK Full Adress

5 of 5

05. One Last Step!

Payment Details

Account number: 20000000000
Bank Name: Taj Bank
Account Name: PSSCOOP

Upload Payment Receipt

I have read and understood the By-Laws of the Public Sector Staff Cooperative Society Limited.

I agree to abide by the By-Laws and any amendments made in the future.

I declare that the information provided in this application form is true and accurate to the best of my knowledge.

Applicant Signature

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