MEMBER REGISTRATION FORM

Were you referred by Pamoja Sacco Team Member*

Yes

If Yes, Enter Name of Pamoja Sacco Team Member

Membership Category*

Normal Member

Sharia Member

Your First Name*

Your Middle Name

Your Last Name*

Gender*

Date of birth*

Month/Day/Year

Mobile Number (KE)

Please provide Kenyan Mobile Number

Mobile Number (CA)

Please provide your Canadian Mobile Number

Email*

Postal Address*

Kenyan Postal Address / Indicate as NA if not applicable

County

Street Address *

Canadian Street Address / Indicate as NA if not applicable

City

Province

Canadian Province or Territory (Optional)

Postal Code

Country of Residence

Nationality*

Verification Document*

Select one or two documents only

Kenyan ID

Kenyan Passport

Canadian Drivers Licence

Canadian Passport

Verification Document Number(s)

List the numbers on the verification documents you are providing

Upload Verification Document(s)

Multiple files allowed. File format in PDF. PNG or JPG

Upload Passport Photo

File format PNG or JPG

Kenyan Bank Name

Bank Branch

Canadian Bank Name

Branch Name

Next of Kin Information

Next of Kin Name

Next of Kin Address

Next of Kin Gender

Next of Kin Relationship