THE WEST INDIAN TOBACCO CREDIT UNION

AND CONSUMER CO-OPERATIVE LIMITED

MEMBERSHIP FORM

FOR NON MEMBERS

RELATIONSHIP TO WITCO EMPLOYEE / WITCU MEMBER __________________________________________

PERSONAL INFORMATION

NEW MEMBER’S NAME

__________________________ _________________________ _______________________

surname first name other name

I am an employee of _______________________________________________________________________________

Permanent Temporary Probation Contract Other _________________

DATE OF BIRTH: ____/____/____ SEX: MALE FEMALE

Day / Month/ Year

MARITAL STAUS: Single Married Divorce Widow Widower Common Law

Please provide two of the following I.D.Card # __________ Passport # _________ Driver’s Liscence # __________
MAILING ADDRESS ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
TELEPHONE NOS. _________________________ _________________________
HOME MOBILE
NATIONALITY _________________________________________
EMPLOYEE NO. (WITCO EMPLOYEES ONLY) _____________
DEPARTMENT ______________________________ OCCUPATION ____________________________

FINANCIAL INFORMATION
I enclose _________________________________________________________________ dollars ($______________)
RECIEPT # _______________________________ DATE PAID______________________________
I the undersigned, hereby apply for membership in the above society. I agree to abide by the bylaws and any subsequent
policies thereof. I also agree to pay an entrance fee of $10.00
PARTICULARS $
Entrance Fees $10.00
Shares
Deposit
Other
TOTAL

NOMINATION OF BENEFICIARY
In the event of sickness or death I nominate Mr/Ms/Mrs _____________________________________ my daughter/son/
father /mother/other(specify)___________________ of (address) ____________________________________________
____________________________________________________________________ to receive my benefits in the Society.
DATE OF APPLICATION __________________________________
PROPOSED BY_______________________________ SIGNATURE ___________________________________

OFFICIAL USE ONLY

APPROVED Not Approved
Chairman ____________________ Remarks _______________________ Account # _________________
Secretary ____________________ _______________________ Group # _________________
Date of Board _______________________ Date entered ________________
Meeting _____________________ _______________________ Initials __________________