KYM- KNOW YOUR MEMBER

1 KYM- know your MEMBER 1. Membership No. : .. 2. Name : (Mr/ Mrs) .. 3. Present Address : .. (please attach address proof) .. 4. Phone No. : .. 5. Mobile No. : .. Sign across the Photo 6. E-Mail ID : .. 7. Bank Account No (Savings / Current). : .. (Please attach a copy of Bank Passbook) 8. Name & Address of Bank: .. 9. Under Section 22 of Act II of 1912, I hereby nominate the following person(s) as heir(s) to whom sum due to me after deducting my liabilities to the above Society, shall be paid in case of my death/ insanity. Nominee 1 : .. (paste photo) Relationship : .. % of Share: .. Address: .. Nominee 2: .. (paste photo) Relationship : .. % of Share: .. Address: .. Declaration: I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately.

2 In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it. I hereby authorize sharing of the information furnished on this form with the NEERI Co-operative Credit Society Ltd. I further authorize the above Society to make e-payment, any sum due to me , as per Society rules, in the Bank Account provided by me. Place : Date : SIGNATURE OF MEMBER Paste your recent color passport size photograph 1st Nominee Sign across the photo 2nd Nominee Sign across the photo INSTRUCTIONS FOR FILLING THE FORM (KYM) - PERSONAL /BANK ACCOUNT DETAILS (a) Form to be filled legibly in BLOCK LETTERS and preferably in BLACK INK. (b) Mention your bank account number in clear handwriting (no overwriting ) and correctly. (c) members should affix his/her one recent colour photograph with white background (size cm x cm) in the space provided on the form.

3 The photographs should not be stapled or clipped to the form. The MEMBER should sign across his/her photograph. (d) members should affix his/her nominees s one recent colour photograph with white background (size cm x cm) in the space provided on the form. The photographs should not be stapled or clipped to the form. The nominee(s) should sign across his/her photograph. (e) While nominating 2(two) nominees as a heir to whom sum due to the MEMBER after deducting his/her liabilities to the above Society, shall be paid in case of his/her death/ insanity, the MEMBER should mention the percentage of share (sum due) which shall be paid to the nominees. I