<% dim dbconn,strConn openDB() action=Request.querystring("action") if lcase(action) = "submit" then 'response.write request.form pSurname = trim(Request.form("pSurname")) pFirstname=trim(Request.form("pFirstname")) pOccupation = trim(Request.form("pOccupation")) pIDno = trim(Request.form("pIDno")) pNhif = trim(Request.form("pNhif")) pPostaddress = trim(Request.form("pPostaddress")) pcode = trim(Request.form("pcode")) sPostalcode = trim(Request.form("postalcode")) pAddress = trim(Request.form("pAddress")) pemail = trim(Request.form("pemail")) pTeloff = trim(Request.form("pTeloff")) pTelmob = trim(Request.form("pTelmob")) pMobile=trim(Request.form("pMobile")) strSQL = "insert into courses (courseTitle,targetParticipant,courseDescription,createdBy,creationDate,lastupdatedon,courseSummary) VALUES ('" & sTitle & "','" & sParticipants &"','"& sDescription & "','"& createdby &"','"& sCreatedon & "','"& sLastupdatedon & "', '" & sSummary & "' )" 'response.Write strSQL 'response.End() dbconn.execute(strSQL) end if %> TTTTT
             
PERSONAL DETAILS TO BE COMPLETED BY POLICY HOLDER(please print)
SURNAME FIRST NAMES     Upload Picture

(Upload and Paste the name of the picture here)
OCCUPATION NATIONAL ID NO    
NHIF NO. POSTAL ADDRESS CODE
PHYSICAL ADDRESS EMAIL    
TELEPHONE NO. OFF RES MOBILE
             
     
     
     
ENTER BELOW DETAILS OF THE POLICY HOLDER(01),SPOUSE(02) WHERE APPLICABLE AND ALL DEPENDANTS TO BE INCLUDED IN THE APPLICATION FOR MEMBERSHIP IN AGE ORDER
SURNAME FIRSTNAME GENDER DATE OF BIRTH   CATEGORY SERVICE COMBINATION FEE
01 M M D D Y Y Y Y   POLICY ORDER KSH
02 <% GenDateDropDown "document.forms[0]", "dateofbirth", setdate, year(NOW())-50, year(NOW())-10, 1 %>   SPOUSE KSH
03 <% GenDateDropDown "document.forms[0]", "dateofbirth", setdate, year(NOW())-50, year(NOW())-10, 1 %>   DEPENDANT KSH
04 <% GenDateDropDown "document.forms[0]", "dateofbirth", setdate, year(NOW())-50, year(NOW())-10, 1 %>   DEPENDANT KSH
05 <% GenDateDropDown "document.forms[0]", "dateofbirth", setdate, year(NOW())-50, year(NOW())-10, 1 %>   DEPENDANT KSH
06 <% GenDateDropDown "document.forms[0]", "dateofbirth", setdate, year(NOW())-50, year(NOW())-10, 1 %>   DEPENDANT KSH
07 <% GenDateDropDown "document.forms[0]", "dateofbirth", setdate, year(NOW())-50, year(NOW())-10, 1 %>   DEPENDANT KSH
 
     
     
     
Are you or any of your family named above,members of any Rescue or Medical Insurance insurance Organisation
  01 02 03 04 05 06 07   TOTAL (KSH)
SUPPLEMENTARY                
OUTPATIENT KSH
PERSONAL ACCIDENT KSH
PERSONAL ACCIDENT $ PERMANENT TOTAL DISABILITY KSH
HOSPITAL CASH KSH
CRITICAL ILLNESS i (500,000.00) KSH
CRITICAL ILLNESS ii (1000,000.00) KSH
                   
     
     
     
PARTICULARS OF NEXT OF KIN & BENEFICIARY OF FUNERAL/PERSONAL ACCIDENT COVER IF DIFFERENT
IF CHILD GIVE DETAILS OF GUARDIAN
NEXT OF KIN (NAME IN FULL)
RELATIONSHIP NATIONAL ID NO./PASSPORT NO.
ADDRESS TELEPHONE NO.
BENEFICIARY OF PA(NAME IN FULL) NATIONAL ID NO
GUARDIAN (NAME IN FULL) NATIONAL ID NO
 
     
     
     
SURNAME FIRSTNAME BLOOD GROUP ALLERGIES HEIGHT(FT/INS) WEIGHT(KGS) PREVIOUS AAR MEMBERSHIP(IF ANY)  
01  
02  
03  
04  
05  
06  
07