First Heritage Co-operative Credit Union Limited

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FHCCU MEMBER APPLICATION FORM

Title / Name

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Surname*

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First Name*

Please enter your First Name

Middle Name*

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Alias

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Home Address*

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# of Years at present address

Please enter Number of years. Number of years must be a number!

Previous Address

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Mailing Address (If different from above)

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Date of Birth*

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Place Of Birth*

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Telephone (Home)

Please use this format 876-123-4567

Telephone (Mobile)*

Please use this format 876-123-4567

Telephone (Work)

Please use this format 876-123-4567

Employment Status*

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# of years employed

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Occupation

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Employer

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TRN*

Please enter your TRN number!

Nationality*

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Country Of Residence*

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Email*

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Sex*

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Marital Status*

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ID Type & #*

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(PURSUANT TO "THE CO-OPERATIVE SOCIETIES' LAW, CAP. 75 OF THE REVISED LAWS OF JAMAICA") I hereby nominate the following person or persons (none of them being an officer or servant of the society, unless such a person is the husband, father, child, brother, sister, nephew or niece of me, the nominator), to or among whom shall be transferred my property in the society, whether in shares, loans, deposits or otherwise at my decease in such proportions as is set forth below opposite their respective names:

By ticking the box, you agree to nominate the following persons, based on the above agreement

Do you Agree?

I AgreeInvalid Input

Account #

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Where the nomination is not intended to comprise the whole of the member’s property, the amount to be comprised is to be specified. Any previous nomination made by me is hereby cancelled.

Note: You can enter information for one or more Beneficiary. You can enter up to six beneficiaries.

Beneficiary 1

Name

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Relation

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Occupation

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Address

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DOB

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TRN

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Proportion

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Beneficiary 2

Name

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Relation

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Occupation

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Address

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DOB

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TRN

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Proportion

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Beneficiary 3

Name

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Relation

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Occupation

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Address

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DOB

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TRN

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Proportion

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Beneficiary 4

Name

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Relation

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Occupation

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Address

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DOB

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TRN

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Proportion

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Beneficiary 5

Name

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Relation

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Occupation

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Address

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DOB

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TRN

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Proportion

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Beneficiary 6

Name

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Relation

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Occupation

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Address

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DOB

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TRN

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Proportion

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Additional Information

Father's Name

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Mother's Maiden Name

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Number of Dependents

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Number of Children

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Name of Spouse

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Occupation Of Spouse

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Place of Employment for Spouse

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Spouse's Work Telephone #

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Name of relative not living with you

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Address of relative

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Annual Income Range

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Kindly indicate the anticipated value of your regular deposits

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Your regular deposits will be made

MonthlyBi - MonthlyWeeklyInvalid Input

Other (Please state)

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Kindly indicate the source of your wealth/funds

SalarySpouseRemittancesInvalid Input

Other (please state)

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Purpose of Account

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Do you or your immediate family (parents, siblings, spouse, children, in-laws and close associates) have prominent public functions locally or in any foreign jurisdiction? This include heads of state or of government, senior politicians, senior government, judicial or security force officials, senior executives

YesNoInvalid Input

If yes, give details

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Name of family member

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Address of family member

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Position/Function

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APPLICATION AGREEMENT

I certify the information above to be true and correct. I further confirm that no information relevant to the Credit Union’s decision to grant membership has been withheld.

I understand that: My account(s) with the Credit Union shall be governed in all respect by the laws and regulations of Jamaica and by the Rules of the Credit Union. I further understand that the Board of the Credit Union reserves the right to terminate my account(s) at any time should any of the information provided be found to be incorrect or if the Credit Union deems the operation of my account(s) to be contravening any law, Regulation and Rule, including the Proceeds of Crime Act and the accompanying Regulation.

The application will not be considered for approval until all the required documents/information have been received and verified where applicable..

Where the document/information is not submitted within 90 days, the relationship will be terminated.

I hereby authorize the Credit Union to obtain independent verification of any information provided in respect of this application.

I declare that I am the beneficial owner of all credits to my account(s)

I understand and agree that the Credit Union may make a charge for the operation of the account(s) to be collected in such manner as the Credit Union from time to time decide and that the rate of charge may be ascertained upon enquiry. It is also agreed that the Credit Union may charge against the said account (s) any indebtedness or liability to the credit union, whether the charges create a debit balance and I shall be and remain liable to the Credit Union in respect of each amount so charged.

I understand that:

Permanent Shares are redeemable only upon transfer to another member of the Credit Union or when terminating my membership, and that they cannot be used as security for any form of assignment or hypothecation for a loan or voluntary commitment of the Credit Union to any third party. By signing below, I also acknowledge receipt of the ATM card Agreement and agree to conform to the Rules and Amendments thereof.

Yes, I AgreeYou must agree, in order to continue!

How did you hear about us?

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Preferred Branch*

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FHCCU MEMBER APPLICATION FORM

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