MEMBERSHIP BENEFITS APPLICATION FORM

PUBLIC SERVICES ASSOCIATION OF TRINIDAD AND TOBAGO

MEMBERSHIP BENEFITS APPLICATION FORM
Please complete in block letters. The completed form must be submitted with copies of identification for all card users.
WHAT IS YOUR MEMBERSHIP STATUS?
NATIONAL ID/PASSPORT/DP
GENDER
FIRST NAME
MIDDLE NAME
LAST NAME
DATE OF BIRTH

DayMonthYear
MARITAL STATUS
MOBILE CONTACT
Format: (000) 000-0000.
OTHER TELEPHONE CONTACT
EMAIL ADDRESS
example@example.com
HOME ADDRESS
PLACE OF EMPLOYMENT
WORK ADDRESS/LOCATION
POSITION
DO YOU OWN A HOME?
DO YOU OWN A VEHICLE?
UPLOAD A PICTURE OF YOUR VALID ID/PASSPORT/DRIVERS PERMIT

VALID IDENTIFICATION ONLY
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PLEASE LIST YOUR DEPENDENTS (I.E. SPOUSE AND/OR CHILDREN UNDER 18 YRS ONLY)

Rows	NAME OF PERSONS (FIRSTNAME LASTNAME)	RELATION	DATE OF BIRTH (DD/MM/YYYY)	IDENTIFICATION NUMBER (ID CARD, DRIVERS PERMIT, BIRTH CERTIFICATE PIN #)	DEPENDENT TO BE LISTED ON YOUR CARD (YES/NO)

APPLICATION ADDITIONAL CARD HOLDER 1 (I.E. SPOUSE AND/OR CHILDREN OVER 18 YRS ONLY) - ANNUAL COST $100.00 PER ADDITIONAL CARD
Name

FIRST NAMEMIDDLE NAMELAST NAME
NATIONAL ID/PASSPORT/DP
DATE OF BIRTH

DayMonthYear
Date
MOBILE CONTACT
Format: (000) 000-0000.
OTHER TELEPHONE CONTACT
EMAIL ADDRESS
example@example.com
ADDITIONL CARD HOLDER 1 - ID / PASSPORT / DP (OPTIONAL)

Cancelof
ADDITIONAL CARD HOLDER INFORMATION 2 (I.E. SPOUSE AND/OR CHILDREN OVER 18 YRS ONLY) - ANNUAL COST $100.00 PER ADDITIONAL CARD
Name

FIRST NAMEMIDDLE NAMELAST NAME
NATIONAL ID/PASSPORT/DP
DATE OF BIRTH

DayMonthYear
Date
MOBILE CONTACT
Format: (000) 000-0000.
OTHER TELEPHONE CONTACT
EMAIL ADDRESS
example@example.com
ADDITIONL CARD HOLDER 2 - ID / PASSPORT / DP (OPTIONAL)

Cancelof
ADDITIONAL CARD HOLDER INFORMATION 3 (I.E. SPOUSE AND/OR CHILDREN OVER 18 YRS ONLY) - ANNUAL COST $100.00 PER ADDITIONAL CARD
Name

FIRST NAMEMIDDLE NAMELAST NAME
NATIONAL ID/PASSPORT/DP
DATE OF BIRTH

DayMonthYear
Date
MOBILE CONTACT
Format: (000) 000-0000.
OTHER TELEPHONE CONTACT
EMAIL ADDRESS
example@example.com
ADDITIONL CARD HOLDER 3 - ID / PASSPORT / DP (OPTIONAL)

Cancelof
Member Signature (Optional but your signature will be required upon collection of your card/s)
DATE

DayMonthYear
Date
Please verify that you are human
Should be Empty:

PUBLIC SERVICES ASSOCIATION OF TRINIDAD AND TOBAGO