Digital Membership Application — Githiga Catholic Church SHG

CARITAS NAIROBI

ARCHDIOCESE OF NAIROBI – SOCIAL PROMOTION REGISTERED TRUSTEE

Membership Application Form

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.

Name of Applicant * National ID / Passport No * Gender * Male Female Marital Status * Married Single Widow Others Date of Birth * Phone No * Current Address * Area of Residence * Town * County * Nationality * Estate / Village Religion * Catholic Non-Catholic

Current Employer / Business Employer / Business Address Period in Current Employment / Business Current Average Monthly Income (KSHS) 0 – 50,000 50,000 – 150,000 150,000 – 250,000 Above 250,000 How did you know about St. John The Evangelist Githiga Catholic Church SHG? Friends Staff / Management Marketing Materials Others If Others, Please Specify

Postal Address Code City Physical Address Email Address Tel No

Attach copy of Marriage Certificate / Affidavit / Birth Certificate or any other proof of legal relationship.

Preferred beneficiary(s) to receive any lump sum benefits payable under the Self-Help Programme Guideline in the event of medically declared insanity, permanent incapacitation or death. Allocation percentages must total 100%.

Full NameRelationshipDate of BirthGenderID / Passport No.Mobile No.Allocation %

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.

National ID / Passport * KRA PIN Certificate * Passport-size Photograph *Use the photo box at the top of the form Next of Kin ID / Passport

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).

I confirm the declaration above and agree to abide by the terms and conditions of the self-help group.

Applicant’s Signature (Type Name) *

Date

Witness Name

Witness Signature (sign after printing)

Witness Membership No.

Witness Date

For Official Use Only

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

MEMBERSHIP NO:

DATE:

VERIFICATION ROLE:

SIGNATURE:

REGISTERED BY:

VERIFIED BY:

APPROVED BY:

Name of Group: St. John The Evangelist Githiga Catholic Church SHG