‘LASS NOTH: THis FORME 1s NOT FOR SALA, REDOWET ANY SUCH PRACTICB TO: 6700.cALL- Sime (0700-225.5646) pe EY a0 4, NATIONAL IDENTIFICATION NUMBER (NIN) lmc ENROLMENT FORM =. PLEASE FLL THE FORMIN BLOCK LETTERS AND TICK AS APPROPRIATE WHAT ARE YOUR NAMES? a STE Wi] Mia/ Mame warms TTT | | [| if a "+ LASTNAME: LL FAST NAME I ‘MIDDLE NAME: CI OTHER NAMES. I MAIDEN NAME: I HAVE VOU CHANGED YOUR NAME BEFORE? A PrefousSumame: TI | [1 Provous Ft Name! Cr previous mda nam Crt | [ARE YOU HOMELESS? YES{ |NO{ ] __ IF NO, WHERE DOYOULIVE? é = TOWN/CITY OF RESIDENCE: TI | RCOUNTRY OF RESIDENCE: [stare OF RESIDENCE: [LOCAL GOVERNMENT AREA OF RESIDENCE: ‘+ ADDRESS OF RESIDENCE: | = DATE OF BIRTH: [= DATE OF BIRTH VERIFICATION. * PLACE OF BIRTH - COUNTRY: = PLACE OF BIRTH STATE: = PLACE OF BIRTH IGA: [ELACE OF ORIGIN STATE t [LACE OF ORIGIN IGA {= PLACE OF ORIGIN TOWN, L T Po ([EBLACE OF ORIGIN- COUNTRY % eet |] t == OF ORIGIN - COUNTRY. 7 PLACE OF ORIGIN - STATE TT t "= PLACE OF ORIGIN (GA. T TT (Fhaceoronait-Town oe LI WHEREIS YOUR MOTHER FROM? @ =A OF ONEN-COUNTAT TEL T THACEGFORGIN SHE | SPACE OFONIGIN-1GA et “= PLACE OF ORIGIN - TOWN, I ‘YOUR PHYSICAL FEATURES 8 (Geeee ern) [emaome] | Marco | | [11 [eneiGrT: ccnumeus | [| _[vismuescans] | omens [| [1 = RESIDENCE STATUS: Tommi | [Nanmeauzarion | | xecisTRaTiON T | '* NATIONALITY: Cy ] I | I 1 ANY PHYSICAL CHALLENGES? ] (lou |_| [earawzeo] — J [_oTwens |_| ‘ABOUT THE CARD Fao Te TT (eS Tes |esl Faso sae =e PEt ‘YOUR NATIONAL IDENTIFICATION NUMBER Fon APPLICANT'S PERSONAL DATA UPDATE ON) K NATIONAL IDENTIFICATION NUMBER (NIN): Ll [uno] (pear —T PLEASE NOTE: THIS FORM 1S NOT FOR SALE. REPORT ANY SUCH PRACTICE TO: 0700-CALLNIMC (070.225.5646)PLEASE NOTE; THIS FORM IS NOT FOR SALE. REPORT ANY SUCH PRACTICE TO: 0700-CALL-NIMC (0700-225-5646) YOUR SUPPORTING DOCUMENTS Ce at | Cl] ee fetes oe OO aa Ct iia heen mr Toot ttt] Coe ‘YOUR OTHER DETAILS ™ (= wanmaL sraTus:—[pwoxcep] [wana lease sas | [seein i [MAIN NATIVE LANGUAGE SPOKEN: [LANGUAGE YOU READ AND ware: Cri OTHER LANGUAGE SPOKEN: Pe L i EDUCATION LEVEL: [CERTIFICATION] [NONE [POST-GRADUATE] [PRIMARY] [SECONDARY] [vexTiaRy] | aguciok: [-ommstane | [stax [_[oawmons [| omit | } joccupanonpaoresson: TT TT TT Ti Pr rr rrr reepvones TT TT TTT TT Errore EMPLOVWENTSTATUS: | awrcove5| | ween | | rannonen [—[saureazove —[_—] SSS In CET CARN pee ete TNO] | = Noee tna ene option Wo inieates COLLECTION AT POINT OF REGISTRATION Temawaooness: | |] 1 | T sa a [- EATHER’S SURNAME: eC "= FATHER’S FIRST NAME: f1 FATHER'S MIDDLE NAME FATHER’S NIN wets [MOTHER'S SURNAME: [= MOTHER'S FIRST NAME, I i T MOTHER'S MIDDLE NAME: T ‘MOTHER'S MAIDEN NAME:| I MOTHER'S NIN ross: t suman RST NAME IDOLE NAME: NATIONAL IGERTIFCATION NUMBER IR NE 2 [= SURNAME OF NEXT OF KI i i ERST NAME OF NEXT OF EN t MIDDLE NAME OF NEXT OF KIN: T t TT ma (Erecationsnie wir next or nel | 1111 111 TTT "ADDRESS OF YOUR NEXT OF KIN @ [= COUNTRY OF RESIDENCE [= STATE OF RESIDENCE [= LOCAL GOVERNMENT AREA OF RESIDENCE, = TOWN/CITY OF RESIDENCE, "STREET ADDRESS. DECLARATION /ATTESTATION z {cer that information provides by me on this for neomplete,trucand aecurteTunderstand tha the information provid by eon thie form. fund my blomesics sll contiate my petal ifonation/data to be cere tothe Nasional Identity Databave consent o shang of my data [povided bere with enantio protic by the NIMC Act 23 of 2007 and within the Nigerian Law. Thereby apply fora National Leeniieation Nutlc (NIN) ana atonal ety (Smart) Cod. Taccep that thio form eaybe sere saved and dbcarded after ure asthe Commissionmay deem, fie widertanal ae accept tha ny iformation uve provided herein not core fale, the Comsmsion reserves the ight of prosecution discoved Applicant's Signature PLEASE NOTE: THIS FORM IS NOT FOR SALE, REPORT ANY SUCH PRACTICE TO: 0700-CALL:NIMC (0700-225-53640)