DOMINICA SOCIAL SECURITY
APPLICATION FOR REGISTRATION AS AN EMPLOYEE
_______________________________________________________________________________
PARTICULARS OF APPLICANT
Social Security Number:
Previous SS Number:
(if applicable)
SURNAME:
COUNTRY OF BIRTH:
MAIDEN NAME (if married)
DAY
MONTH
YEAR
DATE OF BIRTH:
FIRST NAME:
CONTACT NUMBERS:
OTHER NAMES:
MAILING ADDRESS: _________________________________
____________________________________________________
SEX:
Male
Female
____________________________________________________
MARITAL STATUS:
Married
Divorced
Common-law
Single
Separated
Widow/Widower
EDUCATION:
Primary
Secondary
College/Tertiary
University
PARTICULARS OF MOTHER
FIRST NAME
SURNAME (at Applicant’s Date of Birth)
OTHER NAMES
MAIDEN NAME (if married)
PARTICULARS OF SPOUSE
FIRST NAME
SURNAME
OTHER NAMES
MAIDEN NAME (if applicable)
Spouse’s SS Number:
(if applicable)
PARTICULARS OF EMPLOYMENT
OCCUPATION
NAME OF EMPLOYER:
EMPLOYER’S ADDRESS:
COMMENCEMENT DATE OF EMPLOYMENT:
________________________________________________
SALARY/WAGES (W/F/M) ____________________________
________________________________________________
________________________________________________
EMPLOYER’S TELEPHONE #:
I certify to the best of my knowledge and belief, that the above information is true. I am aware that providing false information to the
Dominica Social Security is a criminal offence and will result in the applicable fines and or imprisonment.
________________________________________
_____________________________________
EMPLOYER’S SIGNATURE AND STAMP
EMPLOYEE’S SIGNATURE
DATE: ______________________________
DATE: ___________________________
______________________________________________________________________________________________________________
All applicants must provide their Birth Certificate and Marriage Certificate (if applicable). Non-nationals must provide their passport and
work permit in addition to the other criteria herewith