Form R1 - Application For Employer Registration Page 2
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1
2APPLICATION FOR EMPLOYER REGISTRATION
SOCIAL SECURITY BOARD
CHAPTER 44 LAWS OF BELIZE
SECTION III
ACCESS REQUEST: Online Contributions Portal
I ………………………………………………………………………………………………hereby request access to
the Social Security Board’s (SSB) Online Contributions Portal.
Name of Employer or authorized representative: ..……………………………………………………………
(PRINT IN CAPS)
Signature of Employer or authorized representative: …………………………………………………………
……………../………………/…………………………
Date:
Day
Month
Year
Social Security Board will confirm your registration to the Online Portal via e-mail.
SECTION IV
OFFICIAL USE ONLY
Employer Declaration
Date Received: ________ /______ /_______
I certify the information I have given above is true and correct.
Day
Month
Year
Received By:___________________________
Name: ______________________________________
Industry Code: _________________________
In Block Letters
DE By:________________________________
Signature: ___________________________________
Employer or Authorized Representative
Date: ___________ /______ /_____________
Day
Month
Year
Date: _____________ /_________ /_______________
Received By:___________________________
Day
Month
Year
Date: ___________ /______ /_____________
Day
Month
Year
FORM R1 2013
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