Last Name
Middle Name
First Name
Maiden Name
Previous Name
Alias
Title
MrMissMrs
Other
Sex
MF
Date of Birth
Marital Status
SingleMarriedDivorcedWidowedSeparated
Place of Birth
Telephone Number:
Cell
Work
Home
Nationality
Country of Residence
ID Type
VotersDriver's LicensePassport
ID No.
Expiry Date
TRN No:
Email:
Home Address
Mailing Address (if different)
Previous Address
Occupation
Employer's Name
How long?
Employer's Address
Employer's Telephone No.
Basis of Employment Full timePart time Other
Source of Funds
Purpose of Funds
Estimated Monthly Deposit $
Monthly Income Under $50,000$50,001 - $75,000$75,001 - $100,000$100,001 - $150,000$150,001 - $200,000Over $200,000
Emergency Contact
Type of Reference Member of CU for 2 yrs. or more | Minister of Religion | Principal | Attorney at Law | JP | Medical Doctor | CU Employee at Supervisory level | CU Board or committee member | Police Officer (Rank of Inspector or Higher)
Reference No.1
Reference No.2
PLEASE SUBMIT THE FOLLOWING
Proof of JTA Membership
Valid Photo ID
TRN
Proof of address
Last 2 pay slips Pay Slip 1Pay Slip 2
1 passport sized photograph
I declare that the information provided on this application form is true and agree to notify the Credit Union of any material change thereto. I authorize the Credit Union to obtain any information it may require to process this application. I hereby apply for membership in the JTA Co‐op Credit Union Ltd.
Signature of Applicant:
Signature of Witness:
Date
I, of Being and a member of
A member of the above named Credit Union, do hereby revoke any previous nomination made by me and do hereby Nominate the following as the only person or persons (none of them being an officer or service of the Credit Union, unless such persons is the Husband, Wife, Father, Mother, Child, Brother, Sister, Nephew, or niece of me, the Nominator), to or among whom shall be transferred my property in the Credit Union whether in Shares, Loans, Deposits, or otherwise at my decease in such proportions as is set forth below, opposite their respective names:
I, further appoint the following person(s) as trustee(s) for the minor(s) nominated above until he or she attains the age of eighteen (18) (a Trustee appointed must be eighteen (18) years or older).
IN WITNESS WHEREOF I have hereunto set my hand this
Signature of Member Making Nomination:
Signature of Witness 1
Address:
Signature of Witness 2
I declare that the present nomination was deposited with the Credit Union on
Signature of Secretary or Designate of the Credit Union:
