Application Form for Membership of EBC Funeral CommitteeForm
Application DateDate
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Home Number
*
Home Number
*
Mobile Number
*
Gander
*
Please Select
Male
Female
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Marital Status
*
Please Select
Single
Married
Divorced/widowed
Details of spouse (if married) and children under the age of 16 Residing in Birmingham, United Kingdom
Rows
Name
Date of Birth
Gander
1
2
3
4
5
Please give details of any Medical Conditions for all people on the form.
Type a question
*
I confirm that neither I nor any individuals listed on this form are terminally ill, and that all known medical conditions have been accurately disclosed.
I understand that coverage will not apply for any death occurring within the first year unless it is due to an accident or sudden event.
I, the undersigned, solemnly declare that all information provided in this form is true and complete to the best of my knowledge. I agree to comply with the rules and regulations of the EBC Funeral Death Committee, a copy of which has been provided to me.
I also give my consent to the Islamic Cultural Society to store and use my information solely for the administration of the Death Committee and to contact me when necessary for updates or feedback.
Signature
*
Application DateDate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
File Upload
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