[NSIS FORM | (Enrolment Form) Application for Registration of Citizens, Nation NSIS - MASS ENROLMENT al Identification Number(NIN), National dently Card and Voter Registration veserzor vo {Please Use Capital Letters) hoshaccdl : PART A. [Enrolment Location Code | | OB lolelelolcfolr. 1 |Personal Information [Application 1D i ae chee Slo lolF _ [Sumame |W AN GAL Given Name | (E ty vy A Other Names (AUN otc A Maiden Name Previous Name | oe [se | |Male | | Female | Date OF Birth (DDIMM/YYYY) || 2./1 [0 /2. [© | O| 4] Tek I Estimates Email Home Phone No. Mobile No. contacts | | | Highest Level Of Education | Pp 2 Profession | 2 Occupation | | Disabilities, it any | + [Blind | |Deat Physical a 2 Place of Residence (Tick Appropriate) re Local | |Foreign | ‘Country U Garr Bs Distriot Warm pit ead (County, Lo Braun ‘Sub-County LU RRR Nott | ParstiWard) Vilage Ah SUPA BKE 1 | |__ [Street i : | Plot / House No. ead aaa) |Number of years at this address [0° Previous District Of Residence I i Postal Address. | aa 3 | Place Of Birth (Indicate where you were born in order of District, County,Sub-county,parish and Hospital) Country | Use hy [District VAR One | | County TL ees |Sub-County Luce NSE | ParishWard) uae Village [ ZkSv@n See t | [ciyrtown : Heath Facility - 4 Place Of Origin _ specereeseaeegeaaet | [Country | O GRAN BA ___ [District WOR SA [County ya PSS ‘Sub-County Bum anes | Parish Ward GuamnA |Village “uu Sau a “Indigenous CommuniyTibe | WAU GA Sv Gan | QuU MA | = [By Birth By Registration By Presumption | Citizenship Tyre | ay naturazaton | | oval Chzensip [EyFresowe | |Gitizenship Certifacate Number(it Naturalization, Registration or Dual) eee a | | It Dual, state Citizenship and the other Nationality aaa ceacaaaeaa] || Passport information [Passpod Number | [Fite Number | 4 | Preferred Polling Station Place of Residence | [Place Ot Origin | | Voter's | Name of Poling Station | | Information | previous Voters Number eee ae se eel eee eat ‘Religion aaa ‘Manta Stas | [Married | [Single | [Divorced | [Widowed | [Separated | crick Appropriate) | 5 Spouse Details ‘surname ‘Given Name (Other Names ‘Maiden Name Previous Name National ID Number (NIN) or Application 1D LLLELLEw i I eee - | [By Birth By Registration By Presumption _ fete Tes | —|etnatanaun-| [Dates — [oe | if Dua, state Citzenship and the other Nationality | Place of Marriage | ae Date of Marriage (DD/MM/YYYY) J_| 7 / | : = Type of Marriage | {Civil | Religious. Cultural z ar Manage Coriiate Number ll Id ia Gl i i a a fp [other Spouses (Relerto Amext) |_| Yes No if yes, Number of other spouses ; Page 1 of 3 My Country, My Identity SN:25418913‘ather's details P fBumame TAC CTA (Given Name BAN. S Nu | Previous Name National ID Number (NIN) or Application ID | Citizenship Type |V“|By Birth | |By Registration | [Other Names aid BEATRHEE Dual, state Citizenship and the other Nationality Living Status | [Alive I [Occupation | __|Mother's Place of Residence {Country {County ParishWard | [Street __[Deceased m {Other Names AVL 67 By Presumption (Citizenship Certificate Number Naturalization, Registration or Dual) "|National ID Number (NIN) or Application 1D lek Fl7[glol7l9[i Jololety]2iv ‘Citizenship | _|ByBith| [By Regisaion | |ByPrestimpton | | (ci \ship Certificate Number(if Naturalization, Registration or Dual) peer |Sub-County Village __ [Plot /House No. | of 1/8] (Jo folOl Tit] mA 4A1U9CP CLL rH Dual Citizenship By Naturalization | Dual, state Citizenship and also state other Nationality | |Living Status] | alive | [Deceased | — [Unknown | [Occupation Ter cver pee | Father's Place Ot Residence, : (Country UO OPT dA District MNS OL A aout (County Lu Baca ‘Sub-County Lu gaa Mp tt ParishWard Village YpsSoe, Done F. ‘strest PlovHouso No. Mother's details ae iBeait ecaceell ‘Sumame | VHALASA__[SvenNeme | Previous Name [YAmMpALA 9. a | och [Other Names ‘National ID Number (NIN) or Application ID Citizenship | [By Birth] [By Registration If Dual, state Citizenship and also state other Nationality | jan's Residential Address | District fee a /Sub-County ishWard Village | Street |Plot / House Ne FOR OFFICIAL USEONLY| | | | | | [stea] Registrar/Parish Chiet's Name |» KA RLCUYE, A | “poate oF Regisvaion opmawrrvyy) PPM Py | |Enrolment Officers Name | i smments of Enrolment Officer [Applicant's Signature/Thumbprint i Verification Committee (Parish Chet) page 2 of 3 My Country, My Kdentiy By! Naturaeaton-— izenst fo. [Location [Signature I [Signature | Date | (oom) | [Signature NSIS FORM (Enrolment Form) _