New Membership Application Form SECTION 1: CRITERIA FOR MEMBERSHIPI am a(Required) Minor Adult I am; - (choose one of the following)(Required)-Select One-An employee of the CL Financial GroupAn employee of CLICO Credit Union Co-Operative Society LimitedA member of the Trinidad & Tobago Defence ForceA Relation to an existing CLICO MemberAn employee/student recruited by CCU’s B.D. & Marketing DepartmentName of Company(Required)Job Title(Required) TTR|AG|CG(Required)Regimental Number(Required)Rank(Required)Relationship(Required)Member Name(Required)Name of Company(Required)Name of Organisation(Required)SECTION 2: PERSONAL INFORMATIONName(Required) First Last Residential Address(Required) Street Address Address Line 2 Mailing Address (If different from above) Street Address Address Line 2 Gender(Required)-Select One-MaleFemaleMarital Status(Required)-Select One-SingleMarriedDivorcedSeparatedWidowedCommon LawHome/Mobile(Required)WorkCompanyDate of Birth(Required) DD slash MM slash YYYY Place of Birth(Required) AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Nationality(Required)Identification Information (Only Two (2) valid forms):Nat. ID|DP|PP(Required)Country of Issue(Required)Issue Date:(Required) DD slash MM slash YYYY Expiry Date:(Required) DD slash MM slash YYYY Nat. ID|DP|PPCountry of IssueExpiry Date: DD slash MM slash YYYY Issue Date: DD slash MM slash YYYY Only accepted with Nat. ID or PP;Birth Certificate Pin No:Only accepted with Nat. ID or PPCountry of IssueEmail (Personal) Email (Work) School/University (if applicant is a student):Purpose & Nature Of Business Relationship SHARES DEPOSIT FIXED DEPOSIT MORTGAGE LINCU LOAN SECTION 3: EMPLOYMENT INFORMATIONEmployment Status (Check ALL that may apply): Permanent Contract Casual Self-Employed Temporary Unemployed Retired Employer (current/previous)Employer AddressOccupation/ProfessionDate of Employment DD slash MM slash YYYY Income Cycle Monthly Fortnightly Weekly Daily Annual Income Range $0 - $120,000.00 $120,001 - $300,000.00 $300,000.00 - $500,000.00 $500,000.00+ Method of Deposit-Select-Salary DeductionCash PaymentChequeCredit CardOtherOtherPlease StateEstimated Monthly Contribution to CCU AccountName of BankBank Account #Recommender’s NameRelation to RecommenderRecommender’s Member #Contact #Home/CellSECTION 4: POLITICALLY EXPOSED PERSON (PEP)Politically Exposed Person (“PEP”) includes individuals such as the Head of State, Prime Minister, Head of Government, Government Minister, Parliamentary Secretary, Permanent Secretary, Senior Judicial Official, Senior Military Official, Senior Government Official, Chairman, Director, Commissioner or Chief Executive Officer of a state owned company, Commission or Regulatory Body, Member of the Tobago House of Assembly, Regional Corporation, Statutory Authority or a Senior Member of a political party or a senior politician and important political party officials who are or have been entrusted with prominent functions–, or a relative or known associate of that person.Are you a PEP?(Required) Yes No Are you related to a PEP or any person that holds a High Position in Public Office:(Required) Yes No If yes, Please state relationship(Required)PEP Political Party Official Senior Executive of a State Enterprise Minister of Government Diplomat Member of Judiciary Senior Official employed at a Public Authority Occupy a senior role/position with the military services Occupy a senior role/position with the military servicesIf You have answered yes to any of the questions above, please complete the Additional Information Form. SECTION 5: FOREIGN ACCOUNT TAX COMPLIANCE ACT (FATCA) DECLARATIONAre you a Citizen of any other country than Trinidad and Tobago?(Required)-Select-YesNoIf Yes, Copies of relevant passport(s) to be provided and give details.Upload Passport Drop files here or Select files Max. file size: 20 MB. Are you a U.S. Citizen, Resident or Green Card Holder?(Required)-Select-YesNoDocuments Required - W-9 or W-8BEN - Document Validating US Citizenship - Non-US passport or similar documentation establishing foreign Citizenship Upload Files(Required) Drop files here or Select files Max. file size: 20 MB. Are you a grantee of a Power of Attorney or an Authorized Signatory with a U.S. Address?(Required)-Select-YesNoIf Yes, W-9 or W-8BEN are Documents RequiredUpload W-9 or W-8BEN(Required) Drop files here or Select files Max. file size: 20 MB. Are you giving standing instructions for the transfer of Dividend Income/Regular Income to a U.S. Account?(Required)-Select-YesNoIf Yes, W-9 or W-8BEN are Documents RequiredUpload W-9 or W-8BEN(Required) Drop files here or Select files Max. file size: 20 MB. Are you a person how must comply with Disclosure Requirement of Tax Residency?(Required)-Select-YesNoIf Yes, Please list the Country(ies) of Residency for Tax Purposes and Corresponding Social Security Number (SSN) or Individual Tax Identification Number (ITIN) Details.COUNTRY 1SSN/ITINCOUNTRY 2SSN/ITINCOUNTRY 3SSN/ITIN(FATCA) DECLARATION(Required) If you have ANSWERED “YES OR NO” TO ANY of the questions in this section, please check this box for declarationUNDER PENALTY OF PERJURY, I CERTIFY THAT: I. THE INFORMATION HEREIN IS TO THE BEST OF MY KNOWLEDGE AND BELIEF TO BE TRUE AND CORRECT. II. I AM NOT A CITIZEN OR RESIDENT FOR TAX PURPOSES OF ANY COUNTRY OTHER THAN THOSE LISTED IN THIS SECTION. III. I WILL NOTIFY CCU CO-OPERATIVE SOCIETY LIMITED IMMEDIATELY IN THE EVENT OF ANY CHANGE IN THE INFORMATION STATED IN THIS SECTION. IV. I AGREE THAT CCU CO-OPERATIVE SOCIETY LIMITED CAN PROVIDE TO THE UNITED STATES INTERNAL REVENUE SERVICES (U.S. IRS) AND TO ANY RELEVANT TAX AUTHORITY (OR ANY PARTY AUTHORISED TO ACT ON BEHALF OF SUCH AUTHORITY) AND ANY OF THE INFORMATION PROVIDED IN THIS SECTION OR ANY INFORMATION RELATED TO MY ACCOUNT(S) WITH CCU CO-OPERATIVE SOCIETY LIMITED.SECTION 6 – NOMINATION CERTIFICATEIn the event of death, Ihereby nominateofto receive a sum not exceeding $50,000.00 in accordance with Section 41(3) of the CSA and Section 10(d) and (e) of Bye Laws of the SocietyRelation to MemberContact #Identification # (ID|DP|PP)Date of Issue DD slash MM slash YYYY Date of Expiry DD slash MM slash YYYY Country of IssueEmail Address If the Beneficiary is a minor (under age 18) and does not have a valid form of Identification - Please provide original Birth Certificate. Birth Certificate Pin No.Country of IssueSECTION 7 – DECLARATIONConsent(Required) I agree to Information givenI hereby certify that the information given in this Declaration filed with CLICO Credit Union Co-operative Society Limited is TRUE and CORRECT. By reason that the requirements of the Guidelines on Money laundering for Institutions licensed under the Financial Obligation Regulations, 2010, CCU’s policy requires it to be satisfied as to the source of funds before accepting deposits. Consent is hereby given to CCU to disclose its information to law enforcement authorities. Membership Fee Clause: In accordance with the Credit Union Bye-laws 5(B), membership with the credit union commences from the date of approval, upon payment of a non-refundable entrance fee and the value of at least one (1) full share. All entrance fees applied are credited to the Reserve Fund. The entrance fee serves as a one-time payment required for the initiation of membership and contributes to the overall financial strength and sustainability of the credit union.Signature NameDate DD slash MM slash YYYY SECTION 8 – GENERAL INFORMATIONAre you a bona fide member of any other credit union?(Required) Yes No If yes, please name the credit union:Preferred Method of Communication PHONE CALL E-MAIL TEXT MESSAGE MAIL Would you like to receive email notifications of CLICO Credit Union’s products and services Yes No Upload Required DocumentsClick Here to see all of the Required Documents to UploadUpload Documents Drop files here or Select files Max. file size: 50 MB. CAPTCHA
