TYPE :
ACCOUNT :
Last Name:
Country of R esidence:
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
MOBILE BANKINGXMOBI: YES NO
ONLINE BANKING : YES NO
I hereby authorize the Imarisha to register this account for mobile and online banking
E-mail:Mobile phone no:
APPLICANT DECLARATION
I confirm that the information given above is true to the best of my knowledge.I give authority to Imarisha/Agent to check my Credit ScoreAll copies of documents must be verified either by a Notary Public, or an Appointed Imarisha Agent.
Applicant Signature:
Date:
OFFICIAL USE ONLY
Authorizing Official’s Name:
Signature:
Stamp/Date:
Witness:
Signature:Address:
Date:
Address:
Date:
Witness:
Signature:
Singed in the presence of:
ID/ Documents Authenticated:
Photo Authenticated:
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Mapscent LLC