Application Form for Qualification


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.

[hwp/doc/pdf]Application Form for Qualification