Digital Membership Application

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CARITAS NAIROBI
ARCHDIOCESE OF NAIROBI – SOCIAL PROMOTION REGISTERED TRUSTEE

Membership Application Form

Member No: 0302- Date:

Group Name: GICHARANI SELF HELP GROUP

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

Current Average Monthly Income (KSHS)

0 – 50,000 50,000 – 150,000 150,000 – 250,000 Above 250,000

How did you know about Gicharani Catholic SHG?

Friends Staff/Management Marketing Others:

3. Nomination of Beneficiaries (Page 2)

Full Postal Address

Postal Code

City

Physical Address

Email Address

Full Name of Beneficiary	Relationship	Date of Birth	Gender	Percentage (%)

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. (Giving false information is an offence under the laws of Kenya).

Applicant Signature (Type Full Name)

Witness Name

Witness Membership No

FOR OFFICIAL USE ONLY

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

MEMBERSHIP NO:

	SIGNATURE	DATE
REGISTERED BY:
VERIFIED BY:
APPROVED BY: