TYPE : ACCOUNT : Last Name: Country of Residence: Passport National ID Place of Issue: Female Date of Birth: Passport/ ID Number: Date of Issue: Cell Phone E-mail: Address (Town, City, Country, Code) Mobile Telephone No: Self Employed Occupation/ Designation: Employment Date: EMPLOYMENT/ BUSINESS DETAILS Salaried Name of Employer: Employment Terms: Permanent Contract If Contract, Expiry Date: Student ID No.: Graduation Date: Employer Address (Specify Town, City, Country) STUDENT School Name : IMARISHA SACCO SOCIETY LTD. MOI HIGHWAY, KERICHO/NAKURU ROAD, NEXT TO OILIBYA PETRIOL STATION P.O Box 682-20200, Tel 254-052-21028/30229, KERICHO. Cell 0720 290 22/Call Center 0709 578 000 Email: [email protected] Website: www.imarishasacco.co.ke FOSA Joint Individual BOSA Relationship with Applicant: Gender Male Female NEXT OF KIN: Relationship with Applicant: Relationship with Applicant: Male APPLICANT DETAI LS: First Name Given Name Identification Document: ADDRESS: Applicant Photo Mapscent LLC ------------------------------------------------------------------------------------------------------------------- MEMBERSHIP APPLICATION FORM I hereby make an application for membership in the society and agree to conform to the By-Laws and any amendment thereof, and I will pay Kshs. 360.00 as a membership enrollment fee, and a monthly contribution of Kshs. (minimum of Kshs. 1,600.00 per month, being sum of Depsoit/Shares contribution of Kshs 1,200.00 and welfare contribution of Kshs. 400.00). Student Names: Phone Number : Address (Town, City, Country, Code) Mobile Names: Phone Number : Address (Town, City, Country, Code) Mobile Names: Phone Number : Address (Town, City, Country, Code) Mobile Date of Birth: Date of Birth: Date of Birth: Gender Gender Male Male Female Female