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info@ctcutt.com
#37B Circular Road, San Fernando
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Membership Form
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Your Personal Information
Your Name
*
First
Last
Gender
*
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Female
Date of Birth
*
MM slash DD slash YYYY
Home Phone
*
Marital Status
*
(Please tick One)
SINGLE
MARRIED
WIDOWED
DIVORCED
SEPERATED
COMMON-LAW
Your Email Address
*
Enter Email
Confirm Email
NATIONALITY
National ID
Issue Date
MM slash DD slash YYYY
Expiry Date
MM slash DD slash YYYY
Country of Issuance
DRIVER'S PERMIT
Driver's Permit Number
Issue Date
MM slash DD slash YYYY
Expiry Date
MM slash DD slash YYYY
Country of Issuance
PASSPORT
Issue Date
MM slash DD slash YYYY
Expiry Date
MM slash DD slash YYYY
Country Of Issuance
EMPLOYMENT INFORMATION
Employment Status
PERMANENT
TEMPORARY
CASUAL
SELF EMPLOYED
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RETIRED
Pay Frequency
WEEKLY
FORTNIGHTLY
MONTHLY
Average Monthly Income
Under $3000
$3000 - $6000
$6000 - $9000
$9000 - $12000
Over $12000
Date Joined Company
MM slash DD slash YYYY
Employment Information
Employment Info
Please list your employer, and the position you held
Employer
Occupation
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Employer Address
Address
ARE YOU A MEMBER OF ANY OTHER CREDIT UNION?
YES
NO
ARE YOU A SERVING ON ANY OTHER CREDIT UNION OR STATE BOARD?
YES
NO
IF YES, STATE NAME OF THE C.U:
RECOMMENDATION
Recommender must be a member of the Consolidated Telephones Credit Union
Account Number
DECLARATION
*
I hereby apply for membership in the Consolidated Telephones Credit Union Co-operative Society Limited, and if admitted, I agree to conform to its Bye-Laws or amendments, and pledge to offer my skills towards the further growth of the Credit Union. I also certify that all information given is true and correct to the best of my knowledge and beliefs.
Date Completed
MM slash DD slash YYYY
POLITICALLY EXPOSED PERSONS (PEP)
Have you ever held or currently hold a senior or prominent position in a political or public office?
YES
NO
Please tick if you fall into any of these categories:
Head of State (or Former)
Senior Politicians (or Former)
Senior Members of Legislature (or Former)
Judicial Officials (or Former)
Military Officials (or Former)
Senior Executives of State-owned Corporations (or Former)
Senior Political Party Officials (or Former)
Are you a close associate (socially or professionally) or family member of any of the above?
YES
NO
