Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697630548395.pdf (Antigua and Barbuda)
REQUEST FOR CONTRIBUTION STATUS Self Employed Are you registered with the Medical Benefits Scheme as Self-Employed?
Yes No MBS Registration # _____________________________ Name ________________________________________________ Gender M F Address _____________________________________________________________________________________ Telephone # ______________________/ _______________________/ _______________________ Company/Business Business Registration # _____________________________ Name of Company/Business__________________________________________________________ Address _____________________________________________________________________________________ Telephone # ______________________/ _______________________/ _______________________ CERTIFICATION I _____________________________________________ hereby make application for information regarding contributions paid to the Medical Benefits Scheme by the afore mentioned above.
Please address the letter to ________________________________________________________.

________________________________ Signature _________________________________ Title/Position _________________________ Date REQUEST FOR CONTRIBUTION STATUS OFFICIAL USE Receipt # Research Detail Employer # Employer’s Name Contribution ………………………..……….

Registration Date_____________________ Signature of Clerk REQUEST FOR CONTRIBUTION STATUS