Full Name:*
Middle Name:
Date of Birth:
Previous Name (if ever changed):
Maritial Status*
Country of Birth:*
Country of Residence:*

Two VALID PHOTO I.D. documents must be presented (non-nationals Must present their Passport and local work permit Identification card. Please note that Employer Identifications Cards will not be accepted)

%20 - Upload a Personal Identifier (1):%
%21 - Upload a Personal Identifier (2):%
%89 - Upload a Proof of Home Address:%
%22 - Number of Dependants:%

Evidence of current home address is required, e.g. utility bill - not more than 3 months old (this address must be your residential address), Job Letter, Character Reference Letter or Original of Rental/Lease agreement. A complete listing of the documents acceptable for the purpose of evidencing your current residential address can be had from the “How to Become a Member” document.

Current Residential Address: *
Present Accommodation:*
Please explain for your "Other" response for above question*
Mailing Address (if different from above):
How long have you been at your current address? :
Home Phone #::
Cell Phone #::
Email Address:
Please state your preferred method of contact: :*

(If self employed, please supply supporting documentation in its original form Or a notarized copy (Business License or a Certificate of Good Standing from the relevant body)

Employment Status:*
If your response to the above question is “Other”, please explain:*
Occupation (describe what you do for a living): *
Employer’s Name:
Employers Address:
Employer’s Phone #:
Employer’s Fax #:
How long have you been employed with your current employer?:
If Self-Employed (name and nature of business):
Are you presently entrusted with or intimately related to or closely asociated with a who hold or has held a prominent public position such as that of a Head of State or government, political party official, senior civil servant, senior executive of a state owned corporation, judicial official, senior member of the armed forces and or a member of senior management or executive of a regional or international organization?*
If your response to the above question is “Yes”, please state the position held and the period:*
Are you a citizen or “green card holder” of the United States of America?*

I hereby authorize the verification of the information provided from independent sources. I also authorize the Credit Union to share this information in accordance with all relevant laws and regulations inclusive of but not limited to the Foreign Account Tax Compliance Act (FATCA).

As a requisite of Membership of the Nevis Co-operative Credit Union Limited all members must purchase a minimum of one hundred shares (100) valued at ECD$500.00 at the time of applying for membership of the Credit Union.

Original Source of Funds:
If your response to the above question is “Other” please explain:*
Applicant Income Cycle:*
If your response to the above question is “Occasionally ”, please explain:*
Purpose of the account:
What would be the purpose for the account?*
Source of Ongoing Funds:
What would be the source for the funds?*
Will anyone else besides you deposit funds to your account on a regular basis?:
If yes, please give your reason: *
Which of the following comes closest to your annual income range?
If greater than $96,000.00, please state an approximate amount:
How much do you anticipate depositing regularly to your account? (CHECK the appropriate amount)
If greater than $50,000.00, please state an approximate amount:
Frequency of deposits:*
Frequency of withdrawals:*
By completing and checking the checkbox this application, I acknowledge that I have read and understood this form. To the best of my knowledge and belief, I am an individual who is entitled to become a member of the Nevis Co-operative Credit Union Limited and I know of no circumstances that should prevent me from becoming such a member. The facts herein stated are true and complete to the best of my knowledge, information and belief and I agree to notify the Credit Union of any material change thereto immediately. I agree to conform to the By-Laws and Policies of the Nevis Co-operative Credit Union Limited as amended from time to time. *

This designation is only effective when delivered to and filed with the NEVIS CO-OPERATIVE CREDIT UNION LIMITED.

(State full name below) I, on becoming a member of the Nevis Co-operative Credit Union Limited in accordance with section 106, of the Co-operatives Societies Act, 2011 made there under; and the By-Laws of the above named society, hereby nominate the following as the only person(s) to or among whom to my property in the society, shall be transferred, whether in shares, deposits, or interest held by me in the said society, in the event of my death, in such proportion(s) as is/are set forth below opposite their respective names:
Fill Out:

I further appoint the following person(s) as Trustee(s) for the minor(s) nominated above, until he/she attains the age of Eighteen (18), (any Trustee(s) appointed must be Eighteen (18) years of age or older).