Kganya Botswana Pukwana ya Kganya Payment Book

3 POLICYHOLDER APPLICATION FORM Policyholder Personal Particulars Please complete this form in black ink, using block letters, one letter per block Policyholder No Church Name Church Code Surname First Names Omang Date of Birth Cell No Alt. Cell No New Replacement Continuation D D M M Y Y Y Y D D M M Y Y Y Y Gender (Primary cellphone number) (Secondary cellphone number) Please tick M F I hereby confirm that in applying to become or continue as a Policyholder I have read and agreed to the Declaration as stated on pages 1 and 2 of this Payment Book. Control Number Signature of Policyholder Committee Member Name RG Book Price P90-00 Botswana Surname First Names Omang Cell No Beneficiary for Burial Benefit PERSONAL INFORMATION: Kganya Botswana takes your privacy seriously and respects your personal information. The Privacy Policy tells you how we use your personal information and forms part of our agreement with you. Please read it in the Annexure carefully before providing any personal information to us. Nationality Employment Status Are you a politically exposed person or are you related to one? Employed Self-employed Unemployed Pensioner Y N