Membership Registration Form – Global Elites Cooperative Society

Membership Application Form

Personal Data

Passportupload

Upload Passport

Government Issued IDupload

Upload ID

Surname

First Name

Other Namesyour full name

Date of Birth

Emaila valid email

Phone Number

Residential Addressmore details

0 /

Mailling Addressmore details

0 /

Name of Spouseyour full name

Spouse's Occupationyour full name

Spouse's Employeryour full name

Employment Data

Are you employed?pick one!

YesNo

Status

PermTempContractOther

Name of Employer | Business Nameyour full name

Address of Employer

Employer's Telephone

Occupation

Professionyour full name

Self Employed?

Additional Information

Are you now or have you ever been a member of a credit union?

YesNo

If YES, Provide details:your full name

Personal Referees:

Referee 1

Nameyour full name

Addressyour full name

Mobileyour full name

Relationship

Referee 2

Nameyour full name

Addressyour full name

Mobileyour full name

Relationship

Selection of Beneficiary

I hereby nominate:full name

D.O.B of Beneficiaryof appointment

Relationship

Bank Account Details:

To draw the benefits which may accrue to me under the Statutory Provisions governing the operations of Financial Cooperatives in Nigeria, in the event of my death while a member of Global Elites Cooperative Society.

To Receive:your full name

Percent of any monies accrued to me from the society.

I,your full name

hereby declare and confirm that information given in this application for Global Elites Coop. Society is true and correct and further confirm that I am not engaged in money laundering, drug trafficking, fraud, identity theft or any other crimes or illicit activities. I am aware that I am required by the application agreement to deposit only good items to my account and to refrain from using the account for money laundering, terrorist financing, any other criminal activities, specified offenses or for furthering criminal purposes or conducts. I have not assumed the identity of any other person and the funds/deposites are beneficially owned by me and no one else.

Consentsnt is hereby given to Global Elites Coop. Society to disclose this application, any information contained in it, other related confidential information of mine and current and future deposits and other transactions of mine to the law enforcement agencies, regulatory authorities or other regulated persons.

I promise to abide by the terms of the application agreement and with the statutory provisions and by-laws governing the operation of Global Elites Coop. Society, and I consent to all inquiries the Society may make about me and to the retention of this application and all documents tendered by me in support of this application by the Cooperative Society.

Date Submited

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