Application for Membership - Section 1/4Full Name *Residential Address:NIS#/Social Security#:I am also a member of the following Credit Union/Co-operative Societies:I am also a member of the following Credit Union/Co-operative Societies:Alias:GenderMaleFemaleDate of Birth *Marital StatusMarriedSingleDivorcedWidow(er)Common LawSeparatedChildResidential Status:Place of Birth:Nationality:Mailing Address:Home Phone:Cell Phone:Email Address: *Employment Status:PermanentTemporaryUnemployedSelf EmployedRetiredStudentEmployer / School:Occupation:Work Address:Work Contact:Facsimile :Additional Skills / Training / Certification:Application for Membership - Section 2/4Monthly Income:$0 - $1,000$3,001 - $5,000$7,001 - $10,000$1,001 - $3,000$5,001 - $7,000$10,000 and overInitial Payment:Entrance FeeXCDQualifying SharesXCDEquity SharesXCDDeath Benefit GrantXCDShare DepositXCDOther DepositsXCDApplication for Membership - Section 3/4Identifications Number:Passport #:Issue Date:Expiry Date:Drivers License #:Issue Date:Expiry Date:National ID Card #:Issue Date:Expiry Date:Other:Issue Date:Expiry Date:Recruited by:TVRadioSocial MediaNewspaperMember (state name):Other:Foreign Account Tax Compliant Act (FATCA) DeclarationDo you reside in the United States of America for 183 (6 months) or more consecutive days a year?YesNoAre you a United States of America Citizen or Resident or Greencard holder?YesNoDo you have controlling interest in a company incorporated in the USA or that has a US Address?YesNoAre you a resident in any other country (ies)?YesNoIf yes, please list country (ies)If yes to any of the above, provide your Taxpayer Identifying Number (TIN)Politically Exposed Persons (PEP)Please indicate if you are entrusted or have been entrusted with any of the under-mentioned prominent public function in St. Vincent and the Grenadines or any foreign country:Head of State, Head of Government, Senior PoliticianYesNoParticulars of PEPSenior Government, Judicial or Military OfficialsYesNoParticulars of PEPMembers of Boards of Central BanksYesNoParticulars of PEPAmbassadors and Charges D’affairesYesNoParticulars of PEPSenior Executives of state-owned corporationsYesNoParticulars of PEPImportant political party officialsYesNoParticulars of PEPDirectors and Senior Management of an international organizationYesNoParticulars of PEPMembers of the Board or governing body of an international organizationYesNoParticulars of PEPImmediate family members: Spouse/partner, children and their spouse/partner, parents, grandparents, grandchildren, siblingsYesNoParticulars of PEPClose Associate: Any person who the Credit Union knows to be a close associate of a PEP.YesNoParticulars of PEPApplication for Membership - Section 4/4APPOINTMENT OF NOMINEEIn accordance with Section 105, subsection 1 & 2 of the Co-operative Societies Act No. 12 of 2012, any subsequent amendment made there under, and the Bye-Laws of the above-named Society, I hereby nominate the following person(s) to whom or to whose credit the share, deposit or interest or the value of such shares, deposit or interest held by me in the said Society shall in the event of my death be paid or transferred (in the proportions respectively shown hereunder):Nominee #1:NOMINEERELATIONSHIPADDRESSPortion to be paid or transferred (%)CONTACT NUMBEREMAIL ADDRESSNominee #2:NOMINEERELATIONSHIPADDRESSPortion to be paid or transferred (%)CONTACT NUMBEREMAIL ADDRESSNominee #3:NOMINEERELATIONSHIPADDRESSPortion to be paid or transferred (%)CONTACT NUMBEREMAIL ADDRESSDeath Benefit ApplicationDate of Registration:Beneficiary #1:BeneficiaryRelationshipAddressPercentageBeneficiary #2:BeneficiaryRelationshipAddressPercentageBeneficiary #3:BeneficiaryRelationshipAddressPercentageBeneficiary #4:BeneficiaryRelationshipAddressPercentageATM Card Application - Section 1/3BranchPurpose:New CardReplacement CardLostStolenDamagedOtherATM Card Application - Section 2/3INDIVIDUAL APPLICANT INFORMATIONContact NumbersEmployerMonthly IncomeNo of Years EmployedPrevious EmployerNo of Years EmployedATM Card Application - Section 3/3JOINT APPLICANT INFORMATIONNOTE: This section is only for Joint Account HoldersFull NameGenderMaleFemaleMarital StatusMarriedSingleDivorcedWidow(er)Common LawChildDate of BirthHome AddressMailing AddressContact NumbersHomeWorkCellOccupationMonthly IncomeEmployerNo of Years EmployedPrevious EmployerNo of Years EmployedConsent *Yes, I agree with the privacy policy and terms and conditions.Send Message
