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SHA Application Form

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rosenjeri860
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4K views1 page

SHA Application Form

Uploaded by

rosenjeri860
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Registration Form: The section provides fields for entering personal and employment details for the SHA/SHIF registration.

SANCHEZ CYBER KEROKA

SOCIAL HEALTH AUTHORITY (SHA/SHIF) REGISTRATION FORM

Please fill in the details below to help us complete your SHA/SHIF registration.

1. Full Name (as per National ID): ______________________________________________

2. National ID Number: ______________________________________________

3. Registered Phone Number: ______________________________________________

4. Current Residence Information:


- Estate: ______________________________________
- County: ______________________________________
- Sub-County: __________________________________
- Ward: ________________________________________

5. Employment Status (Select One):


[ ] Employed
[ ] Self-Employed
[ ] Not Employed

6. Income Range (Optional): ______________________________________________

7. Marital Status (Select One):


[ ] Single
[ ] Married
[ ] Divorced
[ ] Widow/Widower

8. Facility Choice (Hospital/Health Center):


_____________________________________________
9. Dependants' Details (if applicable):
- Name(s): _____________________________________
- Relationship: ________________________________
- Date(s) of Birth: _____________________________

Note:
- Please provide documents for dependants if applicable.
- We can assist with the facility choice and dependant additions if you have the necessary
documents.
Signature: ______________________
Date:___________________________

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