The Communal Co-operative Credit Union Ltd. - Grenada



|the COMMUNAL CO-OPERATIVE CREDIT UNION LTD |

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|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: |

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|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: |

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|Address: Occupation: Relationship: |

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|Contact no: % of Estate: |

|2.Last Name: First Name: D.O.B: Marital Status: |

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|Address: Occupation: Relationship: |

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|Contact no: % of Estate: |

|3. Last Name: First Name: D.O.B: Marital Status: |

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|Address: Occupation: Relationship: |

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|Contact no: % of Estate: |

|PLEASE NOTE: |

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|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; |

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|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.  |

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|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. |

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|Signature of Applicant: | Date: |

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| Signature of Interviewer: |Date: |

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|Authorized Signature: |Date: |

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