PCCU PERSONAL ACCOUNT APPLICATION FORM

TAXATION STATUS
YesNo
YesNo

PEP (POLITICALLY EXPOSED PERSON) DECLARATION
APEP is somcone who is or was entrusted with a Prominent Public Function (e.g., head of state or government. politician. judicial or security force officials, senior civil servants. political party officials, ambassadors, senior executive of state-owned corporation or is an immediate family member (e.g., siblings. children. parents. in-laws)or close associate of such person.
YesNo
If yes, please state your position

IDENTIFICATION DETAILS
Passport No.
Issuing Country
Issue Date

DayMonthYear
Date
Expiry Date

MonthDayYear
Date
Identification Type
Issuing Country
No.
Issue Date

MonthDayYear
Date
Expiry Date

MonthDayYear
Date
Identification Type
Issuing Country
No
Issue Date

MonthDayYear
Date
Expiry Date

MonthDayYear
Date
CONTACT DETAILS
Primary Contact No.
Secondary Contact No.
Fax
Email Address
example@example.com
EMPLOYMENT DETAILS

Self-EmployedFull TimePart TimeRetiredStudentUnemployed
Employer Name
Contact Number
Job Title/Occupation
Number of years employed
Name of last employer and tenure (if less than 3 years with present employer)
Employer Address
City & State/Parish
Zip Code
Country

ANNUAL INCOME
$30,000$30,001 - $60,000$60,001 - $90,000$90,001 - $150,000Greater than $150,000
If greater than $150,000. please state amount
ANNUAL INCOME (XCD)

TRANSACTIONS PER MONTH
Cash Deposits
Anticipated Dollar Amount
Cheque Deposits
Anticipated Number of transactions
Cheque Deposits
Anticipated Dollar Amount
Other Financial Institutions
Anticipated Number of transactions
Other Financial Institutions
Anticipated Dollar Amount
WITHDRAWALS
Cash Withdrawals
Anticipated Number of transactions
Cash Withdrawals
Anticipated Dollar Amount
Cheque Withdrawals
Anticipated Number of transactions
Cheque Withdrawals
Anticipated Dollar Amount
ELECTRONIC COMMUNICATION
I/We authorize the Police Co-operative Credit Union (St. Christopher & Nevis) Ltd. to honour any instructions provided by me/us to the Credit Union. via any electronic means of communication including but not limited to telephone. fax or email. The PCCU reserves the right to contact you via telephone number. email or fax listed on its system to confirm instructions prior to honoring transaction requests.

Name of Financial Institution
Name & Designation

REFERENCES
Address
Company
Contact No.
Address
Contact No.
A 'Beneficial Owner' refers to the natural person who ultimately owns or controls a member and/or whose behalf a transaction is conducted.
YesNo

BENEFICIAL OWNERSHIP
IAM the beneficial owner of the account being opened and undertake to notify the Credit Union immediately, in writing. of any change in the beneficial ownership.I AM NOT the beneficial owner of the account being opened. Details of the beneficial owner are as follows:
Name

First NameMiddle NameLast Name
Residential Address
City & State/Parish
Zip Code
Country
Date of Birth

MonthDayYear
Date
Nationality
In accordance with Section 106 of the Co-operatives Societies Act. No. 31 of 2011 made thereunder and the By-Laws of the above named Society. I hereby nominate the following person(s) to whom or to whose credit the share or interest of the value of such share or interest held by me in the said Society shall in the event of my death be paid or transferred (in the proportions respectively shown hereunder Portion to be NameAddressDate of BirthRelationship Paid/Transferred

DESIGNATION OF BENEFICIARIES
Name
Address
Date of Birth

MonthDayYear
Date
Relationship
Portion to be Paid/Transferred
Name
Address
Date of Birth

MonthDayYear
Date
Relationship
Portion to be Paid/Transferred
I further appoint the following person(s) as trustee for the minor(s) nominated above, until he/she attains the age of 18 years. (Trustee(s) must be 18 years of age or older) NameDate of Birth AddressRelationship
Name
Address
Date of Birth

MonthDayYear
Date
Relationship
Name
Address
Date of Birth

MonthDayYear
Date
Relationship
1. I/We authorize PCCU Ltd. (Police Co-operative Credit Union (St. Christopher & Nevis) Ltd to release any information pertaining to the operation of my/our account(s) by mail, fax, or delivery either original or copies of documents any confidential information that you may have in your possession whenever it becomes necessary to do so for the following purposes: a.In order to verify the existence and condition of my account for credit bureaus and like agencies: b. In order to comply with directions of a regulatory body or agency, court orders by any Court of competent jurisdiction within the Federation or under the provisions of any law in the Federation: is c.In order to comply with reasonable and legitimate requests from other financial institutions in circumstances where it necessary for completing business transactions on my behalf; d.In response to requests of persons providing services to the Credit Union as long as those persons maintain confidentiality agreements with you; e.Where you have received written instruction(s)/ permission from myself, my heirs or my legal representatives; and f.In accordance with any laws of the Federation of St. Christopher and Nevis.

2.PCCU Ltd. reserves the right to decline my/our application and no contractual relationship will arise between us: and the Credit Union reserves the right to retain the documents submitted to us with my/our application.

3. I/We agree to inform the Credit Union where there is a change in your occupation, employer, address, mobile number, citizenship or the status of your residency. I/We agree to provide to us such further documents as may be required from time to time to comply with Know Your Member (KYM) requirements. You further understand that the Credit Union reserves the right to close the account in cases where the so required documents are not provided;

4. I/We understand that the continuation of the account is at the sole discretion of the Credit Union and in case the Credit Union is dissatisfied with the conduct of the account, the Credit Union retains the right to close the account after giving notice.

5. That all information provided (including any documents) regarding my/ our application are true and correct to the best of my/our knowledge with the understanding that any misrepresentation could result in the denial of my application.

6.I hereby acknowledge that whereas the above certification is binding me/us and intended for the Credit Union to rely on,I give the credit Union the authority. in addition to the certification to use independent verification of the information given.

7.I hereby acknowledge that I have read. understand and agree to be bound by the terms of the PCCU Ltd. By-Laws.

REFERRAL AND PUBLIC AWARENESS PROGRAM
Name
Contact Number
Email
example@example.com
Revised November 2021 (Previous Edition Obsolete)
Should be Empty:

PERSONAL ACCOUNT APPLICATION FORM

PERSONAL DETAILS - MAIN APPLICANT/PRIMARY ACCOUNT HOLDER

TAXATION STATUS

PEP (POLITICALLY EXPOSED PERSON) DECLARATION

IDENTIFICATION DETAILS

CONTACT DETAILS

EMPLOYMENT DETAILS

ANNUAL INCOME

ANNUAL INCOME (XCD)

SOURCE OF FUNDS

TRANSACTIONS PER MONTH

ELECTRONIC COMMUNICATION

REFERENCES

BENEFICIAL OWNERSHIP

DESIGNATION OF BENEFICIARIES

DECLARATION

FOR JOINT ACCOUNTS ONLY

REFERRAL AND PUBLIC AWARENESS PROGRAM