KNOW YOUR MEMBERS

Member#: *

First Name: *

Last Name: *

Date of Birth *

Place of Birth *

Resident: *

Yes No

Nationality: *

Country of Residence *

Permanent Address: *

Mailing Address:

Same as Above

Telephone Numbers: *

Home:

Work:

Mobile 1: *

Mobile 2:

Email Address: *

Please submit any 2 (two) forms of Identification:

National ID:

Number:

Country of Issue:

Expiry Date (dd/mm/yr):

Driver’s Permit:

Number:

Country of Issue:

Expiry Date (dd/mm/yr):

Passport:

Number:

Country of Issue:

Expiry Date (dd/mm/yr):

1st form of Valid identification (National ID, Drivers Permit, Passport) *

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Please upload the front of your National ID

2nd form of Valid identification (National ID, Drivers Permit, Passport) *

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Please upload the back of your National ID

Address Verification: *

Utility Bill (Electricity / Water / Telephone / Cable) Current Bank Statement Certified Driver’s Permit Other

Attach Document *

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Occupation: *

Name of Business:

Employer: *

Business Address:

Work Address: *

Business Telephone Number:

Work Telephone Number: *

VAT Registration Number (if applicable):

Certificate of Incorporation (if applicable):

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Do you have a side job in addition to your regular occupation? *

Yes No

Are You A Politically Exposed Person? *

Meaning of Politically Exposed Persons (PEPs):

a) Individuals such as the Head of State or Government, senior politician, senior government, judicial or military officials, senior executives of Stateowned corporations and important political officials who are or have been entrusted with prominent functions –

I. By A Foreign Country; Or
Ii. Domestically For Trinidad And Tobago,

b) Persons who are or have been entrusted with a prominent function by an international organization which refers to members of senior management such as directors an members of the board or equivalent functions; (UN, OAS, IADB, ILO, CFATF)

c) An immediate family member of a person referred to in (a) such as spouse, parent, siblings, children and children of the spouse of that person and

d) Any individual publicly known or actually known to the relevant financial institution to be a close personal or professional associate of the persons referred to in (a) or (b) above

Yes No

PLEASE tick if you fall into any of these categories
Are you an INDIVIDUAL, or the IMMEDIATE FAMILY of, or a CLOSE PERSONAL/PROFESSIONAL ASSOCIATE of:

Head of State of Government Senior Politician Senior Government, Judicial or Military Officials Senior Executives of State-owned Corporations Important Political Party Officials

Are You Or Have You Been Entrusted With A Prominent Function By A International Organisation - (Un, Oas, Iadb, Ilo, Cfatf) *

Yes No

If Yes, please provide details:

Name and Address of Foreign Financial Institution:

Telephone No. of Foreign Financial Institution:

1st form of Valid identification (National ID, Drivers Permit, Passport)

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US Citizens or lawful permanent resident

W-9 or W-8BEN

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US Birthplace

W-9 or W-8BEN

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Non-US passport or similar documentation establishing foreign citizenship

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Written explanation regarding US citizenship

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US Address (residence and mailing)

W-9 or W-8BEN

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Non-US passport or similar documentation establishing foreign citizenship

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Instruction to transfer funds to us accounts or direction regularly received from a US address

W-9 or W-8BEN

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Documentary evidence establishing non-US status

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Only address on file is“in care of”or“hold mail”or US PO Box Notice of 2001-34 excludes foreign PO Box as US Indicia)

W-9 or W-8BEN

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Documentary evidence establishing non-US status

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Power of Attorney or signatory authority granted to person with US address

W-9 or W-8BEN

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Documentary evidence establishing non-US status

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I hereby declare that all of the information above is true, accurate and complete and the Credit Union is entitled to rely fully on such information and representation as may be required by law, unless the Credit Union received notice in writing of any change thereafter.

Please select your branch from the options below , then click submit: *

POS Arima San Fernando Tobago

Please submit any 2 (two) forms of Identification:

Are You A Politically Exposed Person? *

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