Youth Membership Application Form – Bethel Credit Union

Personal Information

BranchHead 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

Residential Address

Region

Country

Email Address *

Nationality *

Upload PDF Copy of Birth Certificate *

No file chosen

School Information

Name of School

School Address

Class

School Telephone No.

Parent /Guardian Information

Prefix

First Name *

Last Name *

Date of Birth *

Day

Month

Year

Contact Number

Home No.

Work No.

Cell No. *

Residential Address *

Region *

Country *

Verify Residential Address *

No file chosen

(Utility bill e.g WASA, TSTT, T&TEC, Digicel Play or Bank Statement)

Is your Mailing Address different from your Residential Address? *YesNo

Mailing Address

Region

Country

You are required to provide Two (2) valid forms of Identification

Type of Identification #1You are required to select a unique form of identification.

Type of Identification #2You are required to select a unique form of identification.

ID 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.

Employment Information

Place of Employment *Organization / Business Name

Occupation *

Proof of Income / Employment

Please Specify Other Income

Upload PDF Copy of Document Selected Above *

No file chosen

Recommender Information

Recommender

Recommender Name

Recommender Account NumberYour Account number is the six digit number found after " / " i.e. No. B01C012 / 001234

Financial Obligation Regulation

Are you a politically exposed person? (P.E.P)YesNo

PEP Name

Contact Number *

Residential Address *

Region *

Country *

Source of Wealth

Remuneration *Total amount paid to an employee which may include a salary, commissions, or any other payment.

Asset Value *

Credit Union History

Are you a member of another Credit Union?YesNo

Name of Credit Union

Are you serving on any Credit Union Board of Directors / Committee?YesNo

Name of Committee

Declaration

I hereby apply for membership in Bethel Credit Union Co-operative Society Limited and agree to abide by the bye laws and rules or any amendment thereof the Credit Union. I declare that the information submitted in this application is true to the best of my knowledge. I am not engaged in money laundering, terrorist financing, fraud, drug trafficking, identity theft, or any other criminal or illicit activities. Authorization and consent is given to Bethel Credit Union to obtain information about me and verify the said information.

Note: You are required to complete and submit a Nomination of Beneficiary Form to continue Membership Application.