Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697631794167.pdf (Antigua and Barbuda)
MEDICAL BENEFITS SCHEME SELF-EMPLOYED REGISTRATION FORM Please tell us about yourself 1.

First Name …………….……….…….. 2.

Middle Name(s) …………………………………… (Alias) ……… 3.

Surname ………………………………………….. 4.

MBS No.

……….……….. Soc.

Sec.

No.

……...…...….

5.

Date of Birth ……….…………………………………………………………………………………………….. 6.

Home Address ………………………………………………………………..…………… P.O.

Box# …………… 7.

How long have you lived at this address?

(Date) ………………….……… 8.

Home Tel.

# ……………................ 9.


Email address ……………………………………....... cellular # …………….…………………….

…………... 10.

Are you a Citizen of Antigua and Barbuda?

YES NO 11 11.

Please provide the following documents: (a) A Valid Passport (b) A Valid Work Permit (where required) (c) Documentary Proof of Legal Residency (where required) 12.

Have you ever registered with MBS as a self-employed person?
YES NO If yes, Give details ………………………………………………………………………………………………………………………… Please tell us about your Business 13.

When did you start your business?

(Date) ……….……….

14.

Does your business have a name?

YES NO If yes, Give Business Name ……………………………………………………………………...…………………… 15.

Address ……………………………………………………………………………………….……………..…… 16.

Telephone No.………………………..…… email address…………………………..…………………….…….

17.

What kind of Business/or activity are you engaged in?
(be specific )......................................................................... 18.

What is your position in the Business?

………………………………………………………………………….

19.

Are there other Partners in the Business?

YES NO If yes, please give their names and addresses: - Name………………………….…….

Address…………..…………....... Title…………..………Tel #…………… Name……………………………..…….. Address…………………………...Title……….………… Tel #……...….... 20.
Based on the chart below, please indicate your monthly income category: - Class A B C Monthly Earnings Over $4,500 $3,000.01 to $4,500.00 $3,000.00 and under Rate 5% 5% 5% A B C ($ _______________________) Name of Applicant (print)…………………….……………… Signature…………..............….…………… Title of Signatory……………….……………………………… Date…………………….…………….
OFFICIAL USE Registration Number: ……………………………………… Zone: ………………………………………… Monthly Earnings ($ ______________________________ Deductions $ ______________________ Location where main activities will be or are carried on: (be specific) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Resident status Citizen Temporary Residence Work permit endorsement employment Other prohibited Length of stay granted: From: …………………….……………………… To: ………………………….
…..………………………...… State Other …………………….……….…...… Dispatched documents: Employer letter R3A Comments: …………………………………………………………………………………………………………….…………………………………….

…………………………………………………………………………………………………………….…………………………..….……… ……………………………………………………………………………………………………………………………………………..……….

Registered by: ……………………………………………….…………………………… Date: ……………………………………….……………….
__________________________________________________________________________________________ VERIFICATION Comments/Recommendations: …………………………………………………………………………………………….………………………….

……………………………………………………………………………………………………………..………………….…………..………… ………………………………………………………………………………………………..……………………………………………..……….

I certify that the information contained in the application is complete and accurate, and all required documents have been submitted.
Approval Disapproval Verified by: _________________________________________________________ Employee/Employer Registration & Benefits Eligibility Supervisor Date: _________________________________