Membership Form - Agricola Credit Union Co-operative Society Limited

PERSONAL INFORMATION

Salutation
Mr. Mrs. Ms.

Full Name

Residential Address

Mailing Address

Date Of Birth

Place of Birth
English Spanish French

COUNTRY OF RESIDENCE
ENGLISH SPANISH FRENCH

HomePhone

WorkPhone

CellPhone

UserMail

MARITAL STATUS
SINGLE MARRIED WIDOWED SEPARATED COMMON LAW

ID Choose a file

Max. size: 128.0 MB

BIRTH CERTICIFCATE PIN NO

N.I.S NO

BIR FILE NO. / TAX NO

NEXT OF KIN

Next of Kin Name

Next of Kin Relationship

Next of Kin Contact

EMPLOYMENT INFORMATION

EMPLOYER NAME

WORK ADDRESS

POSITION / OCCUPATION

PERIOD OF EMPLOYMENT

DATE OF EMPLOYMENT

SALARY

PAY CYCLE
MONTHLY FORTHNIGHTLY WEEKLY

EMPLOYMENT TYPE
PERMANENT TEMPORARY CONTRACT

SELF EMPLOYED / PART TIME EMPLOYMENT

OCCUPATION

NAME OF BUSINESS

BUSINESS ADDRESS

BUSINESS TELEPHONE NUMBER

VAT REGISTRATION NUMBER (IF APPLICABLE)

CERTIFICATE OF INCORPORATION (IF APPLICABLE)

GROSS ANNUAL INCOME
< $50,000 $50,000 - $100,000 $100,000 - $200,000 $200,000 - $400,000 >$400,000

BANKING INFORMATION

NAME OF BANK

ACCOUNT #

BRANCH ADDRESS

NAME OF ACCOUNT HOLDER (if different from member)

BRANCH/TRANSIT NUMBER (Mandatory for Scotiabank)

BANK ACCOUNT TYPE:
SAVINGS CHEQUING

Proof of Bank Account Choose a file

Max. size: 128.0 MB

BENEEFICIARY 1 INFORMATION

FULL NAME

RELATIONSHIP

D.O.B

Percentage

RESIDENTIAL ADDRESS

IDs Choose a file

Max. size: 128.0 MB

HOME PHONE

CELL PHONE

BENEEFICIARY 2 INFORMATION

FULL NAME

RELATIONSHIP

D.O.B

PERCENTAGE

RESIDENTIAL ADDRESS

IDS Choose a file

Max. size: 128.0 MB

HOME PHONE

CELL PHONE

BANKING INFORMATION

NAME OF BANK

ACCOUNT #

BRANCH ADDRESS

NAME OF ACCOUNT HOLDER (if different from member)

BRANCH/TRANSIT NUMBER (Mandatory for Scotiabank)

BANK ACCOUNT TYPE:
SAVINGS CHEQUING

Proof of Bank Account Choose a file

Max. size: 128.0 MB

BENEEFICIARY 1 INFORMATION

FULL NAME

RELATIONSHIP

D.O.B

Percentage

RESIDENTIAL ADDRESS

IDs Choose a file

Max. size: 128.0 MB

HOME PHONE

CELL PHONE

The Co-operative Societies Act Chapter 81:03 states: A society shall subject to Section 30 and unless prevented by order of a Court of competent jurisdiction and in conformity with Section 41 (3) (as amended via Section 8 of Act No. 23 of 2019 cited as Finance Act, 2019) pay to such nominee or legal personal representative, as the case may be, a sum not exceeding fifty thousand dollars ($50,000.00) due to the deceased member from the Society. All other monies due to the deceased member from the Society shall fall into his estate and be subject to all respects of the laws relating to inheritance including the requirements to pay estate duty.

BENEEFICIARY 2 INFORMATION

FULL NAME

RELATIONSHIP

D.O.B

PERCENTAGE

RESIDENTIAL ADDRESS

IDS Choose a file

Max. size: 128.0 MB

HOME PHONE

CELL PHONE

DECLARATION

I hereby declare that the above information is true and correct to the best of my knowledge and I shall immediately update AGRICOLA Credit Union if there is any change in such information. I authorize AGRICOLA Credit Union to verify any or all information provided. I hereby promise to abide by the rules and regulations made and to be made of the Credit Union. I agree to indemnify the Society against any loss, claims, damages, liabilities or actions and legal proceedings and or other expense which may be directly or indirectly incurred as a consequence of incorrect or misleading information given by me. In addition, I/we also give AGRICOLA Credit Union Cooperative Society Ltd, permission to obtain any credit report on my financial position from time to time throughout the duration of any loans being held with the organization.
YES

BLAH BLAH TRANSUNION