Membership Application Form - SVG Teachers Co-operative Credit Union Ltd

Application for Membership - Section 1/4

Full Name *

Residential Address:

NIS#/Social Security#:

I am also a member of the following Credit Union/Co-operative Societies:

Alias:

Gender

Date of Birth *

Marital Status

Residential Status:

Place of Birth:

Nationality:

Mailing Address:

Home Phone:

Cell Phone:

Email Address: *

Employer / School:

Occupation:

Work Address:

Work Contact:

Facsimile :

Additional Skills / Training / Certification:

Application for Membership - Section 2/4

Monthly Income:

$0 - $1,000

$3,001 - $5,000

$7,001 - $10,000

$1,001 - $3,000

$5,001 - $7,000

$10,000 and over

Initial Payment:

Entrance Fee

XCD

Qualifying Shares

XCD

Equity Shares

XCD

Death Benefit Grant

XCD

Share Deposit

XCD

Other Deposits

XCD

Application for Membership - Section 3/4

Identifications 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 MediaNewspaper

Member (state name):

Other:

Foreign Account Tax Compliant Act (FATCA) Declaration

Do you reside in the United States of America for 183 (6 months) or more consecutive days a year?

Yes

No

Are you a United States of America Citizen or Resident or Greencard holder?

Yes

No

Do you have controlling interest in a company incorporated in the USA or that has a US Address?

Yes

No

Are you a resident in any other country (ies)?

Yes

No

If 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 PoliticianYesNo

Particulars of PEP

Senior Government, Judicial or Military OfficialsYesNo

Particulars of PEP

Members of Boards of Central BanksYesNo

Particulars of PEP

Ambassadors and Charges D’affairesYesNo

Particulars of PEP

Senior Executives of state-owned corporationsYesNo

Particulars of PEP

Important political party officialsYesNo

Particulars of PEP

Directors and Senior Management of an international organizationYesNo

Particulars of PEP

Members of the Board or governing body of an international organizationYesNo

Particulars of PEP

Immediate family members: Spouse/partner, children and their spouse/partner, parents, grandparents, grandchildren, siblingsYesNo

Particulars of PEP

Close Associate: Any person who the Credit Union knows to be a close associate of a PEP.YesNo

Particulars of PEP

Application for Membership - Section 4/4

APPOINTMENT OF NOMINEE

In 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:

NOMINEE

RELATIONSHIP

ADDRESS

Portion to be paid or transferred (%)

CONTACT NUMBER

EMAIL ADDRESS

Nominee #2:

NOMINEE

RELATIONSHIP

ADDRESS

Portion to be paid or transferred (%)

CONTACT NUMBER

EMAIL ADDRESS

Nominee #3:

NOMINEE

RELATIONSHIP

ADDRESS

Portion to be paid or transferred (%)

CONTACT NUMBER

EMAIL ADDRESS

Death Benefit Application

Date of Registration:

Beneficiary #1:

Beneficiary

Relationship

Address

Percentage

Beneficiary #2:

Beneficiary

Relationship

Address

Percentage

Beneficiary #3:

Beneficiary

Relationship

Address

Percentage

Beneficiary #4:

Beneficiary

Relationship

Address

Percentage

ATM Card Application - Section 1/3

Branch

ATM Card Application - Section 2/3

INDIVIDUAL APPLICANT INFORMATION

Contact Numbers

Employer

Monthly Income

No of Years Employed

Previous Employer

No of Years Employed

ATM Card Application - Section 3/3

JOINT APPLICANT INFORMATION

NOTE: This section is only for Joint Account Holders

Full Name

Gender

Marital Status

Date of Birth

Home Address

Mailing Address

Contact Numbers

Home

Work

Cell

Occupation

Monthly Income

Employer

No of Years Employed

Previous Employer

No of Years Employed