The Communal Co-operative Credit Union Ltd. - Grenada
|the COMMUNAL CO-OPERATIVE CREDIT UNION LTD |
|[pic] |
|MEMBERSHIP ApplicatION FORM |
|Account no: |
|Branch: Date: Previous Member: Choose an item. |
|Last Name: First Name: Other name (s): |
|Home address: Parish: Country: |
|Mailing address: |
|Identification: #: SSN/TIN: |
|Date of Birth: |
|Place of Birth: Country of Residence: Dual Citizenship: |
|Marital Status: Sex: |
|Telephone nos: Home: Work: Mobile: |
|Email address: |
|Mother’s Name: |
|Employment Information |
|Current Employer: |
|Employer’s Address: |Date of Employment: |
|Occupation: |
|Other Income: |
|Source of Funds to open the account: |
|Expected Average Monthly Deposits: |
|PROOF OF ADDRESS |
|UTILITY BILL PRESENTED: |
|REFERENCE |
|Name: |
|Address: |
|Contact #: |
|Relationship: |
| |
|OTHER DETAILS |
|Are you a Politically Exposed Person (PEP)? |
|Are you a US Resident, US Citizen, US Permanent Resident Card Holder? |
|Do you hold a Power of Attorney or have signatory authority for anyone residing in the USA? |
|BENEFICIARY INFORMATION |
|1.Last Name: First Name: D.O.B: Marital Status: |
| |
|Address: Occupation: Relationship: |
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|Contact no: % of Estate: |
|2.Last Name: First Name: D.O.B: Marital Status: |
| |
| |
|Address: Occupation: Relationship: |
| |
|Contact no: % of Estate: |
|3. Last Name: First Name: D.O.B: Marital Status: |
| |
|Address: Occupation: Relationship: |
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|Contact no: % of Estate: |
|PLEASE NOTE: |
| |
|To become a full member you must purchase forty (40) Permanent Equity Shares at $5.00 each and pay a non-refundable Registration Fee of $30.00; |
| |
|To become a temporary member, you can purchase a minimum of twenty (20) shares at $5.00 each. You become a full member when the remaining sixty (20) shares are purchased |
|within three (3) months of the application for membership; and |
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|Your Permanent Equity Shares must be maintained at $200.00 and is not withdrawable. |
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|I confirm that the information provided by me in this application is true and correct. I also declare that I am not involved in money laundering or Terrorism Financing |
|activities, drug trafficking, theft, fraud, tax evasion, identity theft, political corruption or any other criminal activity. I understand that the funds to be deposited |
|to this account should not be proceeds from illegal activities and should only be good items from a legitimate origin. I give my consent and fully understand that all the |
|information submitted by me and all activities on my account(s) may be made available to law enforcement and regulated authorities, other financial institutions, other |
|authorized persons or as mandated by the Court. |
| |
|I promise to abide by the terms and conditions of this account agreement, the retention of this application and all documentation that may be submitted by me during the |
|course of the account relationship. I give full permission to all enquiries the Credit Union may make about me. I understand that the Credit Union is mandated by law to |
|carry out these and other regulated procedures with which I am willing to co-operate. |
| | |
|Signature of Applicant: | Date: |
| | |
| Signature of Interviewer: |Date: |
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|Authorized Signature: |Date: |
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