Scribd
Upload
32 views

Membership Form (2)

Uploaded by

abdirashid2012
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
32 views

Membership Form (2)

Uploaded by

abdirashid2012
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

MEMBERSHIP APPLICATION FORM

P.O.BOX 2392-00606, WESTLANDS (Please sign within the Box)


TEL: +254722004065 (020) 4274065
JCC:+254722002685 (020)4272685 SIGNATURE
EMAIL: [email protected] AFFIX
www.safaricomsacco.co.ke PHOTO
@Safaricom Sacco HERE

Please complete in full in BLOCK Letters. This form is complete when attached: One recent COLOURED
Passport Photograph, Copy of ID and Copy of KRA PIN.
I hereby make an application for membership and agree to conform to the Cooperatives By-Laws and
any amendment thereof.

PERSONAL PARTICULARS (As per ID or Passport)


FIRST MIDDLE SURNAME

GENDER ID/PASSPORT NUMBER DATE OF BIRTH


M F D D M M Y Y Y Y

POSTAL ADDRESS

PHYSICAL ADDRESS

EMAIL ADDRESS TELEPHONE (PREFERABLY MOBILE NUMBER)

EMPLOYER & PARTICULARS OF OCCUPATION

COMPANY NAME

STAFF NUMBER

PROFESSION

1
IF JOINING AS AN INDIVIDUAL FILL IN PHYSICAL LOCATION OF BUSINESS & POSTAL ADDRESS

WHO INTRODUCED YOU TO SAFARICOM SACCO

MEMBER NAME (Tick Below) MEMBER NUMBER CHAMPION FACEBOOK TWITTER OTHER

I the undersigned, upon my demise whilst a member of the society, hereby instruct the society to pay all amounts due to me
less any debts to the society, to the person(s) named in this section. The name(s) of nominee(s) can be given in sealed
letter. I understand that I may alter the name of nominated next of kin by filling in a subsequent nominated next of kin form.
NO. NOMINATED NEXT OF RELATIONSHIP ID/PP NO. DATE OF PHONE Percentage
KIN/S PHONE NO. If BIRTH NUMBER (%) Assigned
Minor indicate (D.O.B)
C/o
1.
2.
3.
4.
5.
REMMITANCES
I hereby authorize you to deduct Kshs. _______________________ Monthly Deposits Contribution and Kshs. ________________ Share
Capital Contribution from my Salary and/or any other mode of Remittance and pay Safaricom Sacco Ltd with effect from the month
of _________________________ until further notice. Membership of Kshs 1,000.00 will be deducted with the 1st deduction from payroll OR
any other mode of Remittance arrangement with the society.

MODE OF PAYMENT
YOU NEED TO BE CONSISTENT ON A TICK APPROPRIATELY BANKS MPESA
MONTHLY BASIS
EMPLOYER (CHECK OFF)
CASH (OVER THE COUNTER)
STANDING ORDER or DDA
LIPA NA MPESA (SACCO PAYBILL 505100)
FOSA STANDING ORDER

All payments to be made to Safaricom Sacco Limited: Cooperative Bank; Westlands Branch; Acc No
01120061487800 OR NIC Bank; Westlands Branch; 1000426306
________________________________________________________________________________________________________________________________________

SIGNATURE OF APPLICANT (Within the Box)


FOR SOCIETY USE ONLY
ENTRANCE FEE (1000/-) PAID ON …………………………….. RECEIPT NO……………………………………
DATE OF ADMISSION TO MEMBERSHIP ……………………………………………………………………………
ACTIONED BY……………………………………………………………………………………………………………………………………..…
CHECKED BY: ………………………………………………………………………… MEMBERSHIP NO……….............. DATE ……………………………

You might also like