REGISTRATION FORM

Date of Birth Member/

Gender Address
DD/MM/ City of Employee Dependant
Title Surname Firstname Other Name Female or (No
YYYY Residence number Indicator
Male commas)
(13/05/1974) O or D

MR Okorie Chikezie 22/07/1981 M 116 OrimeruIbafo O

MRS Okorie Funmilayo Elisabeth 4/5/1986 F 116 OrimeruIbafo D
MISS Okorie Chielotem Mercy 28/11/2014 F 116 OrimeruIbafo D
MISS Okorie SomtochukwEsther 18/12/2017 F 116 OrimeruIbafo D
MR Okorie EzuemokeniMathew 8/11/2019 M 116 OrimeruIbafo D
MR Onaleye Jesulayomi Emmanuel M 116 OrimeruIbafo D
MR Oyedele Ayobami John M 116 OrimeruIbafo D
Relationship
to main
Marital
member
status (Single Phone number Email
(Self, Spouse,
or Married)
Son or
Daughter)

SELF Married 8063823670 chikezie.okorie@wtl.be

SPOUSE Married 8130115745 chikeziemokorie@gmail.com
DAUGHTE Single
DAUGHTE Single
SON Single
SON Single
SON Single