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: info@imarishasacco.co.ke 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:

-------------------------------------------------------------------------------------------------------------------

Mapscent LLC