Membership Application Form – Progressive Credit Union

Name

First Name *

Last Name *

Address

Street Address *

Street Address Line 2

City *

Country *

Nationality (Country) *

Date of Birth *

Phone Number (Cell) *

Phone Number (Home)

Email *

ID, Passport, DP# *

Occupation *

Employer Name *

Sources of Income

Sources of Income0 - 4,9995000 - 9,99910,000 - 19,999over 20,000

Marital StatusSingleMarriedDivorcedCommon-Law

Name of Spouse

First Name

Last Name

Spouse Telephone Number

Reason/Purpose of AccountSavingsLoanInsuranceOther

Reference 1 Name

First Name

Last Name

Reference 1 Relationship

Reference 1 Telephone Number

Reference 1 Street Address

Reference 2 Name

First Name

Last Name

Reference 2 Relationship

Reference 2 Telephone Number

Reference 2 Street Address

Beneficiary Name

First Name

Last Name

Beneficiary Relationship

Beneficiary Telephone Number

Beneficiary Address

Beneficiary Address Line 2

Section C - Politically Exposed Person (P.E.P)

Are you a current or former member of any of the following classes:

Heads of GovernmentYesNo

Senior official in the executive, legislative, administrative or judicial branch of a local or foreign government, whether elected or not ?YesNo

Senior politician or senior official of a major political party ?YesNo

Senior executive of a government-owned commercial enterprise?YesNo

An immediate family member of a person mentioned in the questions above meaning spouse, parents, siblings or children of that person and the parents, siblings and additional children of the person's spouse whether half or whole blood?YesNo

Close personal or professional associate of a person mentioned in questions 32 - 36 above ?YesNo

If Yes, Provide Details

Name of Applicant

First Name

Last Name

Date

DECLARATION I hereby apply for membership in the Progressive Credit Union Co-operative Society Ltd and if admitted, I agree to conform to the Bye-Laws or amendments thereof of the said Society.

Signature

Please upload your proof of ID, utility bill, Job letter and recent payslip.

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