CCCU Membership Application Form CCCU BASE# PERSONAL INFORMATIONApplicant's Name* Day* Month* Year* GENDER* MALE FEMALE ID CARD/EXPIRY DATE PASSPORT/EXPIRY DATE DRIVER'S PERMIT/EXPIRY DATE BIRTH CERTIFICATE PIN HOME ADDRESS* MAILING ADDRESS* CERTIFIED BY ATTACHED UTILITY BILL* YES NO MARITAL STATUS* SINGLE MARRIED WIDOWED DIVORCED SEPERATED COMMON LAW NAME OF SPOUSE NUMBER OF DEPENDANTS NAME OF CHILD/SPOUSE/SIBLING/PARENT/GRANDPARENT WHO IS A MEMBER OF THIS SOCIETY OFFICE No. HOME No. MOBILE No. EMAIL EMPLOYMENT INFORMATIONNAME OF EMPLOYER* ADDRESS OF EMPLOYER* OCCUPATION/PROFESSION* SALARY FREQUENCY* MONTHLY FORTNIGHTLY WEEKLY EMPLOYMENT STATUS* PERMANENT SELF EMPLOYED CONTRACT RETIRED CASUAL TEMPORARY INCOME CATEGORY* UNDER $1500 $1501-$3000 $3001-$4500 $4501-$6000 $6001-$7500 $7501-$9000 $9001-$11000 OVER $11000 KNOW YOUR MEMBERA "politically exposed person" means a person who is or was entrusted with important public functions such as: (a) a current or former senior official in the Executive, Legislative, Administrative or Judicial branch of government, whether elected or not; (b) a senior official of a major political party; (c) a senior executive of a government-owned commercial enterprise; (d) a senior military official; (e) an immediate family member of a person mentioned in paragraphs (a) to (d) meaning the spouse, parents, siblings or children of that person and the parents, siblings and additional children of the person's spouse. (f) A close personal or professional associate of the person mentioned in (a) to (d). Questionnaire to be completed in accordance with the Laws of Trinidad and Tobago relative to 'Know Your Customers'. Please complete by ticking the boxes below that are applicable to you:T&T NATIONAL* YES NO DO YOU HAVE DUAL CITIZENSHIP* YES NO U.S RESIDENT* YES NO If Yes please state your IRS Tax Number Other (Please State) DIRECTOR OF A STATE BOARD* YES NO A MEMBER OF THE JUDICIARY* YES NO MINISTER OF GOVERNMENT* YES NO A SENIOR OFFICIAL AT A PUBLIC AUTHORITY* YES NO DIPLOMAT* YES NO OCCUPY A SENIOR ROLE/POSITION WITHIN THE MILITARY SERVICE* YES NO NAME OF PERSON OCCUPYING THE POST In the event of sickness or death, I hereby nominate Relationship to Applicant Address of Beneficiary Phone Contact No. RECOMMENDED BY (Recommender must be a member in good standing for six months) RELATIONSHIP TO APPLICANT SIGNATURE OF RECOMMENDER CCCU ACCOUNT NUMBER Date MM slash DD slash YYYY
