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 #
Invalid Input

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)

Email
Invalid Input Email

Gender
Invalid Input

Marital Status
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)

Share/Deposit Method
Invalid Input

Monthly Salary (Gross)
Invalid Input

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
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

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?
Invalid Input

If yes, please specify name (s)
Invalid Input

Were you previously a member of KCCU?
Invalid Input

If yes, give full name used at that time
Invalid Input

7. UNDISCHARGED BANKRUPT
Invalid Input

If yes, Date of bankruptcy filing:
Invalid Input

Country
Invalid Input

8. RESIDENCE
Invalid Input

Other
Invalid Input

9. INDUSTRY
Invalid Input

Other
Invalid Input

10. HIGHEST LEVEL OF EDUCATION REACHED
Invalid Input

Other
Invalid Input

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