Membership Application Form | Bethel Credit Union

Personal Information

Branch *Head Office - #31 Bethlehem Road, BethelMt. Marie Branch - Mt. Marie, Lower Scarborough

Prefix

First Name *

Middle Name

Last Name *

Date of Birth *

Day

Month

Year

Age

Gender

Marital Status *

Residential Address *

Region

Country

No. of Years at Address

Upload Proof of Residence *

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Utility Bill e.g. WASA, TSTT, T&TEC, Digicel or Bank Statement

Is your Mailing Address different from above?YesNo

Mailing Address

Region

Country

Email Address *

Nationality

Contact Number

Home No.

Work No.

Cell No. *

Note: You are required to provide the following documents with your application:

Two (2) valid forms of Identification
Birth Certificate

ID #1 *

ID #2 *

ID #1 Number *

ID #2 Number *

Upload PDF Copy of ID #1 *

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Note: Only PDF files can be uploaded.

Upload PDF Copy of ID #2 *

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Upload PDF Copy of Birth Certificate *

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Next of Kin

Next of Kin´s Name

Relationship

Contact No.

Place of Employment

Foreign National

Would you like us to transact business with a foreign bank?YesNo

Name of Foreign Bank

Account No.

Address of Foreign Bank

Bank Contact No.

Type of Financial Institution

Type of Reference received

Authority Type

Employment Information

Employer Name / Company

Company Address

Company Contact No.

Job Title Occupation *

Date of Employment

Day

Month

Year

Remuneration FrequencyHow often you are paid for your service(s)?

Evidence of Employment *Job LetterPay SlipContractOther

Upload Proof of Employment *

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Letter of Employment, Pay Slip, Pension Statement, Proof of Other Income or Last Financial Statement

Financial Obligation Regulation

Are you a registered business owner?

Legal Arrangement

Business Name

Business Contact No.

Politically Exposed Persons (P.E.P)

In accordance with the Proceeds of Crime Act 2000 (as amended) and the Financial Obligations (amendment) Regulations 2014, Regulation 20(3), there is an obligation for Financial Institutions to undertake Enhanced Member Due Diligence on clients who are classified as a PEP. As defined by these acts and adopted within the Bethel Credit Union Co-operative Society AML/CFT Programme, a PEP shall be considered as an individual who is or has been entrusted with a prominent function either locally or in a foreign country.

Are you a Politically Exposed Person? (PEP) *YesNoA PEP is defined as a person who is or has been entrusted with a prominent public function. Such persons include: Head of State; Head of Government; Members of Parliament; Senior members of the Legislature, Senior political party officials; Senior executives of State owned corporations including those bodies where the state has controlling interest; close associates and immediate family of the PEP. This includes spouse, siblings, children and parents and the parents, siblings and additional children of the PEP’s spouse.

Select one or as many of the P.E.P. categories below that best describe you;

Head of StateHead of GovernmentSenior Members of the Legislature e.g. Speaker of the House & President of SenateSenior Government Officials e.g. Permanent Secretaries, Chief Technical Officers & Ambassador or High Commissioner, Assistant Commissioner of Police or higher rank.Judicial Officials – e.g. Magistrates, Judges of the Supreme Court, Judges of the Industrial Court, Judges of the Caribbean Court of JusticeMilitary Officials - Lieutenant Colonel or higher rankSenior executives of State-owned corporation e.g. Members of the Boards of all Statutory Bodies and State Enterprises including the CONTROLLING Interest of StateSenior political party officials e.g. Chairman, Political Leader & Deputy Political Leader

International Organization PEP

United Nations and affiliated International OrganizationInter-American Development BankCaribbean Financial Action Task ForceOrganization of American StatesInternational Labour Organization

Organization *

Job title *

PEP Organization Address

PEP Organization Contact Number *

RemunerationHow much you are paid for your service(s)?

PEP Name *

PEP Address

PEP Contact Number *

Source of Wealth

AssetsValue of assets owned.

Immediate Family Member of a PEP:An individual who is related to a PEP either through birth or marriage (current or past).

CLOSE ASSOCIATE OF A PEP: *Please indicate relationship to and name of PEP named

Based on my responses to the above *I confirm that I am a Politically Exposed Person (PEP)I confirm that I am not a Politically Exposed Peron (PEP)

Student

Are you a Student? *YesNo

Level of Educational Institution

Name of School

Address of School

Form/Class/Year

Major/Minor

Minor

Under 16 years

Is the applicant a minor (under 16 years)? *YesNo

Name of Parent/Guardian

Address of Parent/Guardian

Place of Work of Parent/Guardian

Job Title of Parent/Guardian

Relationship to Applicant/Minor *ParentLegal GuardianOther

Specify Relationship to Applicant/Minor

Authorisation for operation of a Minor´s Account

AUTHORISATION FOR OPERATION OF A MINOR’S ACCOUNT: The person indicated below is hereby duly authorized to make withdrawals or access on this account and on behalf of the applicant who is a minor.

Name of Authorised person on Account

Specimen Signature of Authorised Person *

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Relationship of Authorised Person to Minor

Gender *

Authorised Person ID #1 *

Upload PDF Copy of Identification *

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Authorised ID #2 *

Upload PDF Copy of Identification *

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Declaration

Are you a member of another Credit Union? *YesNo

Name of Credit Union

Are you currently serving on the Board of a Credit Union?YesNo

Name of Committee

I hereby apply for membership in BETHEL CREDIT UNION CO-OPERATIVE SOCIETY LIMITED, and, if admitted, I agree to conform to the Bye Laws or amendments thereof of the said Society, and pledge to offer my skills towards further growth of the Credit Union.
I further declare that all information provided and contained herein is true and correct to the best of my knowledge.

Are you signing on behalf of an Applicant who is a minor?YesNo

Upload PDF Copy of Signature *

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Recommender

Recommended By

Please specify other

Recommender’s First Name

Last Name

Account No. of ReccommenderNote: Your Account number is the six digit number found after " / " on your passbook i.e. No. B01C012 / 001234

What inspired you to join?

SharesLoanFixed DepositCUNA Products (FIP)

Beneficiary Information

Number of Beneficiaries

Beneficiary First Name (1) *

Beneficiary Last Name (2) *

Type of Identification (1) *

National Identification CardDriver's Permit / LicensePassport

You are required to provide two (2) unique forms of identification for the beneficiary.

National ID Number *

Driver´s Permit Number *

Passport Number *

Upload PDF Copy of Identification *

No file chosen

Note: Only PDF files can be uploaded.

Upload PDF Copy of Identification *

No file chosen

Note: Only PDF files can be uploaded.

Beneficiary's Address *

Region

Country

Beneficiary Home TEL. No. *

Beneficiary Mobile No. *

Beneficiary's Email Address

Relationship with Beneficiary *

Beneficiary First Name (2) *

Beneficiary Last Name (2) *

Type of Identification (2) *

National Identification CardDriver's Permit / LicensePassport

You are required to provide two unique forms of identification for the beneficiary.

National ID Number *

Driver´s Permit Number *

Passport Number *

Upload PDF Copy of Identification *

No file chosen

Note: Only PDF files can be uploaded.

Upload PDF Copy of Identification *

No file chosen

Note: Only PDF files can be uploaded.

Beneficiary's Address *

Region

Country

Beneficiary Home TEL. No. *

Beneficiary Mobile No. *

Beneficiary's Email Address

Relationship with Beneficiary *

I understand in the event of my death, if I do not name a beneficiary, the proceeds of this account will be paid into my Estate and distribute according to the Succession Act 1981 of Trinidad and Tobago. I further declare that all information given herein is true and correct to the best of my knowledge.