KYM- KNOW YOUR MEMBER
1.
Membership No.
:
……………………………………………………………………
2.
Name
:
(Mr/ Mrs) …………………………………………………………
3.
Present Address
:
……………………………………………………………………
(please attach address proof)
Paste your
recent color
passport size
photograph
………………………………………………………..
……………………………………………………………………
……………………………………………………………………
4.
Phone No.
:
…………………………………
5.
Mobile No.
:
…………………………………
6.
E-Mail ID
:
……………………………………………………………………
7.
Bank Account No (Savings / Current). : ……………………………………………….
(Please attach a copy of Bank Passbook)
8.
Name & Address of Bank: ……………………………………………………………..
9.
Under Section 22 of Act II of 1912, I hereby nominate the following person(s) as heir(s) to whom sum due to
Sign across the Photo
me after deducting my liabilities to the above Society, shall be paid in case of my death/ insanity.
Nominee 1 :
……………………………………………………………………
(paste photo)
Relationship : ………………….. % of Share: ……………..
Address: ………………………………………………………
……………………………………………………….
Nominee 2:
……………………………………………………………………
(paste photo)
Relationship : ………………….. % of Share: ………………
Address: ………………………………………………………
……………………………………………………….
st
1
Nominee
Sign
across
the photo
2nd
Nominee
Sign
across the
photo
Declaration: I hereby declare that the details furnished above are true and correct to the best of my knowledge
and belief and I undertake to inform you of any changes therein, immediately. In case any of the above
information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable
for it. I hereby authorize sharing of the information furnished on this form with the NEERI Co-operative Credit
Society Ltd. I further authorize the above Society to make e-payment, any sum due to me , as per Society rules,
in the Bank Account provided by me.
Place :
Date :
SIGNATURE OF MEMBER
P.T.O.
INSTRUCTIONS FOR FILLING THE FORM (KYM) - PERSONAL /BANK ACCOUNT DETAILS
(a) Form to be filled legibly in BLOCK LETTERS and preferably in BLACK INK.
(b) Mention your bank account number in clear handwriting (no overwriting ) and correctly.
(c) Members should affix his/her one recent colour photograph with white background (size 3.5 cm
x 2.5 cm) in the space provided on the form. The photographs should not be stapled or clipped to
the form. The member should sign across his/her photograph.
(d) Members should affix his/her nominees’s one recent colour photograph with white background
(size 3.5 cm x 2.5 cm) in the space provided on the form. The photographs should not be stapled
or clipped to the form. The nominee(s) should sign across his/her photograph.
(e) While nominating 2(two) nominees as a heir to whom sum due to the member after
deducting his/her liabilities to the above Society, shall be paid in case of his/her death/ insanity,
the member should mention the percentage of share (sum due) which shall be
paid to the nominees.
I