WELFARE REGISTRATION FORM

HAMISI WEST BODABODA ASSOCIATION

P.O. Box 53 Vihiga
Office Located at Hamisi Phone numbers 0715 396 888/ 0717 900 192

1. Principal member’s details

Surname ………………………………………………
First name ………………………………………………
Other names ………………………………………………
ID No. ………………………………………………
Date of Birth ………………………………………………
Membership No. ………………………………………………
Present Physical Address ………………………………………………
Group Details ………………………………………………
Group Chairperson name ………………………………………………
Phone No. ………………………………………………
Signature ………………………………………………
Home physical address ………………………………………………

Village ……………………………………………… Sub location ………………………………………………

Ward……………………………………………… Sub County………………………………………………….
Constituency………………………………………………County………………………………………………
Mobile Phone Number ………………………………………………

2. Next of Kin/Beneficiaries

Name of next of Kin Age Relationship Physical Mobile Number

(Yrs) Address

Approved by:
Sub County welfare leader
………………………………………….
Sub County officials
………………………………………….