Membership

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Membership

1. PERSONAL (APPLICANT)

First Name(*)

Invalid Input

Other Name

Invalid Input

Surname(*)

Invalid Input

Alias

Invalid Input

Date of Birth(*)

/ / Invalid Input

Country of Birth

Invalid Input

Country of Citizenship/Residency

Invalid Input

Passport #

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ID Card #(*)

Invalid Input

Driver's License

Invalid Input

Address

Invalid Input

Postal Code

Invalid Input

Fixed Telephone

Invalid Phone Number (123-456-7890)

Cell

Invalid Phone Number (123-456-7890)

Invalid Input Email

Gender

FemaleMale Invalid Input

Contact Name

Invalid Input

Contact Relationship

Invalid Input

Contact Address

Invalid Input

Contact Telephone

Invalid Phone Number (123-456-7890)

Contact Cell

Invalid Phone Number (123-456-7890)

2. EMPLOYMENT (APPLICANT)

Employer

Invalid Input

Lenght of Employment (years)

Invalid Input

Occupation

Invalid Input

Employer Telephone

Invalid Phone Number (123-456-7890)

3. SELF EMPLOYMENT (APPLICANT)

Nature of Business

Invalid Input

Business Start Date

Invalid Input

Owner Drawings (monthly) EC$

Invalid Input

Your Position

Invalid Input

Annual Revenue EC$

Invalid Input

Business Incorporated

YesNo Invalid Input

Name of Business

Invalid Input

Expected Value of Business Monthly:

Withdrawals EC$

Invalid Input

Deposits EC$

Invalid Input

4. NOMINEE
In accordance with section 102 of the Co-operative Societies Act 12 of 2012, the Byelaws and any other relevant regulations. I hereby nominate the following person (or persons) to whom or to whose credit the share or interest or the value of such share 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 --

Name

Invalid Input

Date of Birth

/ / Invalid Input

Address

Invalid Input

Telephone

Invalid Phone Number (123-456-7890)

Proportion %

Invalid Input

-- Nominee 2 --

Name

Invalid Input

Date of Birth

/ / Invalid Input

Address

Invalid Input

Telephone

Invalid Phone Number (123-456-7890)

Proportion %

Invalid Input

-- Nominee 3 --

Name

Invalid Input

Date of Birth

/ / Invalid Input

Address

Invalid Input

Telephone

Invalid Phone Number (123-456-7890)

Proportion %

Invalid Input

-- Nominee 4 --

Name

Invalid Input

Date of Birth

/ / Invalid Input

Address

Invalid Input

Telephone

Invalid Phone Number (123-456-7890)

Proportion %

Invalid Input

5. PAYMENT

Required: Entrance Fee $5.00 - Permanent Share Account: A minimum of 20 shares at $5.00 each

Permanent Shares Account

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Optional

Redeemable shares $

Invalid Input

Deposit $

Invalid Input

Death Benefit $

Invalid Input

Medical Insurance $

Invalid Input

Christmas Savings $

Invalid Input

Vacation Savings $

Invalid Input

KCYC Plus $

Invalid Input

6. CREDIT UNION MEMBERSHIP

Are you a member of any other Credit Union in SVG?

YesNo Invalid Input

If yes, please specify name (s)

Invalid Input

Were you previously a member of KCCU?

YesNo Invalid Input

If yes, give full name used at that time

Invalid Input

7. UNDISCHARGED BANKRUPT

YesNo Invalid Input

If yes, Date of bankruptcy filing:

Invalid Input

Country

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8. RESIDENCE

Own homeRentLive with Parents Invalid Input

Other

Invalid Input

9. INDUSTRY

Other

Invalid Input

10. HIGHEST LEVEL OF EDUCATION REACHED

Other

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