Membership Application Form

Member No: 0302- Date: Photo No:

1. Copy of national ID/passport

3. Copy of next of kin national ID/passport

2. Copy of KRA PIN certificate

4. Passport size photograph

I hereby apply for membership and agree to conform and abide by the self-help group’s by-laws, regulations, guidelines and amendments thereof.

1. Applicant Information

Name of Applicant

National ID / Passport No

Gender

Male Female

Marital Status

Date of Birth

Phone No

Nationality

Religion

Catholic Non-Catholic

Current Address

Area of Residence

Town

County

Estate / Village

2. Source of Income

Current Employer / Business

Period in Employment (Years)

Employer / Business Address

Monthly Income (KSHS)

3. Nomination of Beneficiaries

Postal Address

Code

City

Physical Address

Tel No

Full Name	Relationship	Date of Birth	Gender	%

I nominate the person(s) named above to be my preferred beneficiary(s) to receive any lump sum benefits payable under the Self-Help Programme Guideline in the event of my medically declared insanity, permanent incapacitation or death.

4. Next of Kin

Full Name

Relationship

Mobile Phone No

ID No

5. Declaration & Witness

I declare all information given herein is true and shall abide by the terms and conditions laid down by the self-help group. (Note: Giving false information is an offence under the laws of Kenya).

Applicant’s Signature (Type Name)

Date

Witness Name

Witness Signature

FOR OFFICIAL USE ONLY

We have checked and confirmed that all the information given above is correct:

MEMBERSHIP NO: DATE:

Verification Role	SIGNATURE	DATE
REGISTERED BY:
VERIFIED BY:
APPROVED BY: