Part-Time Credit Union

Membership Application

ACCOUNT NUMBER

PERSONAL INFORMATION

First name Last Name

Middle Name Alias (if any)

Male: Female: D.O.B:

IDENTIFICATION

Social Security Passport Driver’s License National ID ID Number Country

ID Number Country

Country of Birth Nationality

Dual Nationality Yes No Tax ID Number

Address

Tel: Email address:

Marital Status: Single Married Cohabiting Divorced Widowed Number of Dependents:

Are you a Politically Exposed person (PEP)? Yes No Are you a member of another Credit Union? Yes No

INCOME /EMPLOYMENT DETAILS

Which of the following best describes your occupation? (Please tick one box only) Employed Full-time Employed Part-time Self Employed Retired Unemployed House person Student Minor Pensioner

Employer Name:

Employer Address:

Business Tel: Job Title:

Nature of the business if self-employed

Time with this employer/self-employed: Years Months Monthly Income range: $0-$1000 $1001-$2500 $2501-$3500 $3501-$4500

$4501-$5500 $5501- $7000 over $7000 Other Income $ Source of funds to be deposited

Estimated amount to be deposit $

monthly

weekly bi-weekly

annually

BENEFICIARY NOMINATION

In the event of your death, who do you nominate as your beneficiary to receive any and all sums of money standing to the credit of your shares or deposits account or paid under and by virtue of terms and conditions of the Life Insurance Contract, Life Savings Plan of CUNA Mutual Insurance Society to the said Credit Union? 1. Relationship D.O.B

2. Relationship D.O.B

3. Relationship D.O.B

4. Relationship D.O.B

5. Relationship D.O.B

BENEFICIARY INFORMATION

#1.Address Tel Allotted %

#2.Address Tel Allotted %

#3.Address Tel Allotted %

#4.Address Tel Allotted %

#5.Address Tel Allotted %

Witness name: Signature:

Witness name: Signature:

Applicant Signature: Date:

FOR OFFICIAL USE ONLY

Account # Date opened:

Risk: High Medium: Low: PEP

Approved by: Date:

Contact this candidate