1. PERSONAL (APPLICANT) Full Name * Alias Date of Birth * Country of Birth Citizenship/Residency Passport # ID Card # Driver’s License # Permanent Address Postal Address Fixed Tel # Cell # Email * Gender MaleFemale Marital Status MarriedSingleDivorcedWidowedSeparated 2. EMPLOYMENT (APPLICANT) Employer Length of Employment (years) Occupation Employer Tel. Share/Deposit Method Direct DeductionCounterRemittance Monthly Salary (Gross) 500–15001501–25002501–35003501–5000>5000 3. SELF‑EMPLOYED APPLICANTS Nature of Business Business Start Date Owner Drawings (Monthly) EC$ Your Position Annual Revenue EC$ Business Incorporated YesNo Name of Business Expected Monthly Withdrawals EC$ Expected Monthly Deposits EC$ 4. NOMINEE You may nominate up to four; leave unused rows blank. Nominee 1 Name Date of Birth Address Telephone # Proportion % 5. PAYMENT Entrance fee: $5.00 (fixed) Permanent Shares: Min 20 shares @ $5.00 each Redeemable Shares EC$ Deposit EC$ Death Benefit EC$ Medical Insurance EC$ Christmas Savings EC$ Vacation Savings EC$ KCYC Plus EC$ 6. CREDIT UNION MEMBERSHIP Member of other Credit Union? YesNo If yes, name(s) Previously KCCU member? YesNo If yes, full name used 7. UNDISCHARGED BANKRUPT Bankrupt? YesNo If yes, date of filing Country 8. RESIDENCE Housing Status Own homeRentLive with parentsOther If Other, specify 9. INDUSTRY Industry LegalMedicineFinanceEngineeringAccounting/AuditManufacturingAgriculture/FisheriesConstructionHuman ResourcesMarketing/PRHospitalitySportsOther If Other, specify 10. HIGHEST LEVEL OF EDUCATION REACHED Education PrimarySecondary/High SchoolA LevelCollegeUniversityTechnicalProfessionalVocationalOther If Other, specify 11. DECLARATION Name of Declarant Of (Address / Company) Date Member’s Signature Signature Date Attesting Witness 1 Date Attesting Witness 2 Date
