N S S E N R O L M E N T F O R M

PHOTO ON NATIONAL ID UPLOADED PHOTO

NSS NumberNSSAHC4836923
:

PIN: ZZQAHC6492323

National ID Ghana
Card

ID Number GHA-
724170965-
1

PERSONAL INFORMATION
NAME ON NATIONAL ID : BIYERINGUNY EMMANUEL TIA

Surname: BIYERINGUNY Other Names : EMMANUEL TIA

Name Of Institution: Course Of Study: DOCTOR OF MEDICAL

LABORATORY SCIENCE

Sex: Male Date of Birth: 21-12-1997

Marital Status : Single Nationality : Ghana

Contact Tel No.(s) : +233553885439 Email Address : biyeringuny85@gmail.com

Residential Address : KB37 KUMBUYILI

Ghana GPS Digita Address : NS-344-5574: Residential Region NORTHERN

GUARDIAN INFORMATION
Guardian Name : TIA BIYERINGUNY

Guadian Email : biyeringuny85@gmail.com Guadian Phone No +233249958475

NEXT OF KIN INFORMATION

Name of Next of Kin: BIYALGUNI MODESTA Kin's Contact No. : +233591278324

Relationship: SISTER

EMPLOYMENT HISTORY & OTHER INFORMATION

Are you currently employed? No Study Leave Type:

The Organization you work

with(Your Study Leave
Sponsor):

Organization Phone #:

Do you have any health condition? No Health Condition Type:

Health Condition Details:

Do you have Military Training?* No Have you done Service Before*: No

Organization you have

served before:

POSTING PREFERENCES INFORMATION

Region I: NORTHERN Region II: AHAFO Region III: SAVANNAH

INDUSTRIAL PREFERENCE - SERVICE OPTION

Service Option Community Health Service Option Urban Sanitation Entrepreneurship
I:: II: Type: