Application Form for Qualification
The Self-employed Insured □
The Employee Insured □
①
Household(whole) □
WorkplaceCorporatIon
② Code No.
Household(partial) □ (Card No: )
③ Name
□ Householder
□ Employee Insured
⑥ Name
⑦ No. of
Foreign Registration
⑧ Date of
Registration/Employment
⑨ Nationality
⑩ Status of Sojourn
④ Unit site
code
name
⑤ Business
office
code
name
⑪ Address
Cellular Phone( )
□□
ID
NE
SP
UE
RN
ED
DA
NT
⑫Relation
⑬ Name
⑭ No. of
Foreign Registration
⑮ Date of
Registration /Employment
Nationality
Status of Sojourn
Resident
period
Declaration of Contribution, etc.
Monthly
Wages
Accounting
code
Contribution Reduction
Job Category
code
code
I hereby register alien eligibility acquisition in accordance with the article 45 of the National Health Insurance Enforcement Decree.
Enrollee : (Signature)
(Employer) (Official Seal)
President of the National Health Insurance Corporation
Note) Please, refer to the back page for your help in filling out the form. |
2007.11.28
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