INSESO · FORMS

Affiliation form

Complete the form in capital letters. Fields reserved for INSESO are completed at the office.

Choose what to do with your form. To print, the server places your details in the original template. You can download the form without entering any details.

Fields marked * are required. Sections reserved for INSESO are completed at the office.

01 Personal details

First name *Use letters, spaces, hyphens or apostrophes (2–120 characters).Surname *Use letters, spaces, hyphens or apostrophes (2–120 characters).Date of birth *Place of birthMaximum 180 characters; do not use < or >.

Document type *Select one option only.

DIPPassportResidence

Personal document number *3–60 characters: letters, numbers, spaces, full stops, slashes or hyphens.Marital statusMaximum 180 characters; do not use < or >.CountryMaximum 180 characters; do not use < or >.Phone6–26 characters: numbers, a + prefix, spaces, hyphens or parentheses.Father’s nameUse letters, spaces, hyphens or apostrophes (2–120 characters).Mother’s nameUse letters, spaces, hyphens or apostrophes (2–120 characters).

02 Bank details

Bank nameMaximum 180 characters; do not use < or >.BranchMaximum 180 characters; do not use < or >.Current account number6–40 characters: letters, numbers, spaces or hyphens.

03 Home address

Neighbourhood / streetMaximum 180 characters; do not use < or >.Community / villageMaximum 180 characters; do not use < or >.Town or cityMaximum 180 characters; do not use < or >.

04 Relationship with INSESO and current employment

Relationship with INSESOYou may select several options.

WorkerPensionerPerson with a disability

Current employer’s nameMaximum 180 characters; do not use < or >.Current positionMaximum 180 characters; do not use < or >.Current salaryNon-negative amount, without thousands separators; up to two decimal places.Date of hiring

05 Company activity details

Activity nameMaximum 180 characters; do not use < or >.Activity typeMaximum 180 characters; do not use < or >.Business sectorMaximum 180 characters; do not use < or >.Neighbourhood / streetMaximum 180 characters; do not use < or >.Community / villageMaximum 180 characters; do not use < or >.Town or cityMaximum 180 characters; do not use < or >.

06 Employment history

Name of previous employer · 1Maximum 180 characters; do not use < or >.Employment start date · 1Employment end date · 1Name of previous employer · 2Maximum 180 characters; do not use < or >.Employment start date · 2Employment end date · 2Name of previous employer · 3Maximum 180 characters; do not use < or >.Employment start date · 3Employment end date · 3Name of previous employer · 4Maximum 180 characters; do not use < or >.Employment start date · 4Employment end date · 4Name of previous employer · 5Maximum 180 characters; do not use < or >.Employment start date · 5Employment end date · 5PlaceMaximum 180 characters; do not use < or >.Date

07 Section reserved for INSESO

Affiliation number (reserved for INSESO)Date received (reserved for INSESO)Registration date (reserved for INSESO)Officer responsible (reserved for INSESO)

PhotoTo be completed by INSESO

Applicant’s or responsible person’s signature

Sign with my name Sign by hand after printing

Signatory’s full name *

Enter your name and confirm the declaration. You may also draw your signature with a mouse or finger.

I confirm that I am the signatory and that the information provided is correct. *This typed-name signature does not include a digital certificate.

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