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?*

ORDINARY MEMBERHONORARY MEMBER (RETIRED)NON - MEMBERPSA STAFFEXECUTIVE OFFICER
NATIONAL ID/PASSPORT/DP*
GENDER*

MALEFEMALE
FIRST NAME*
MIDDLE NAME
LAST NAME*
DATE OF BIRTH*

DayMonthYear
MARITAL STATUS*

MARRIEDSINGLECOMMON LAWOTHER
MOBILE CONTACT*
OTHER TELEPHONE CONTACT
EMAIL ADDRESS*
example@example.com
HOME ADDRESS*
PLACE OF EMPLOYMENT*
WORK ADDRESS/LOCATION*
POSITION*
DO YOU OWN A HOME?

YESNO
DO YOU OWN A VEHICLE?

YESNO
UPLOAD A PICTURE OF YOUR VALID ID/PASSPORT/DRIVERS PERMIT*

VALID IDENTIFICATION ONLY
Cancelof

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

	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

MALEFEMALE
Name

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

DayMonthYear
Date
MOBILE CONTACT
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

MALEFEMALE
Name

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

DayMonthYear
Date
MOBILE CONTACT
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

MALEFEMALE
Name

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

DayMonthYear
Date
MOBILE CONTACT
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)

Clear
DATE*

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

PUBLIC SERVICES ASSOCIATION OF TRINIDAD AND TOBAGO