TitleMr.Mrs.Ms.Dr.HonProf.OthersFirst Name *Surname *OthernamesIdentification DocID NoPasport NoNationalityAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwePhone *Email Address *Street Address *CityZIP / Postal CodeCountry *AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweUpload ID Front *jpeg, png, jpgChoose FileNo file chosenDelete uploaded fileUpload ID Back *jpeg, png, jpgChoose FileNo file chosenDelete uploaded fileUpload Signature *jpeg, png, jpgChoose FileNo file chosenDelete uploaded fileUpload Passport Photo *jpeg, png, jpgChoose FileNo file chosenDelete uploaded fileUpload KRA PIN *pdfChoose FileNo file chosenDelete uploaded fileHow would you like to receive your membership confirmation? *How would you like to receive your membership confirmation?EmailPhoneBothQONAPAY / iCONNECT REGISTRATIONFunds disbursed to FOSA A/C are accessible through mobile hence QONAPAY registration is to facilitate moving funds to your M-PESA A/C or transfer to your bank account.M-PESA Registered Number: *Membership Registration Fee Ksh 1000 *Input MPESA code if you have already paid the membership registration feeEMPLOYMENT DETAILSEmployer:Occupation:Employee Position:Staff No:Gross Income Per Month (KSh):Below 100K100-499K500K- 999K1M-3MAbove 3MIF JOINING AS AN INDIVIDUAL FILL IN PHYSICAL LOCATION OF BUSINESS & POSTAL ADDRESSNature of Business eg. Law firm, Tech firm, Advertising Agency:Business Name:Physical Location of Business:Business eMail Address:Business Registration No:Gross Income Per Month (KSh):Below 100K100-499K500K- 999K1M-3MAbove 3MWHO INTRODUCED YOU TO QONA SACCO?Referral Member Name:Member No:Social MediaXInstagramFacebookYouTubeWEBWebsiteGoogle SearchNEXT OF KIN DETAILSI the undersigned, upon my demise whilst a member of the society, hereby instruct the society to pay all amounts due to me less any debts to the society, to the person(s) named in this section. The name(s) of nominee(s) can be given in sealed letter. I understand that I may alter the name of nominated next of kin by filling in a subsequent nominated next of kin form.SelectSpouseSonDaughterSibling(Brother/SisterMotherFatherName *Percentage *Next of kin PercentageSelectSpouseSonDaughterSibling(Brother/SisterMotherFatherName *Percentage *Next of kin PercentageREMMITANCESI hereby authorize you to deduct Deposit Contribution from my Salary and/or any other mode of Remittance and pay QONA SACCO Ltd KShs.(Min 3000 - Max any amount )I hereby authorize you to deduct Share Capital Contribution from my Salary and/or any other mode of Remittance and pay QONA SACCO Ltd KShs.(Min Deposit is 3400 -Max any amount )Membership of KShs 1,000 will be deducted with the 1st deduction from payroll OR any other mode of Remittance arrangement with the society with effect from until further notice. *PREFERRED MODE OF PAYMENT?PREFERRED MODE OF PAYMENTEmployer (Check-Off)Standing OrderFOSA Standing OrderCash Over the CounterLipa na M-PESADATA PROTECTION ACKNOWLEDGEMENT & CONSENT *I, hereby acknowledge, that I have read and understood the Sacco’s Data Privacy Notice and General Terms andConditions, as well as applicable laws and regulations of Data Protection in Kenya. I understand how my personaldata will be collected, processed, stored, and used by the Sacco and its authorized entities. By signing thisacknowledgment, I consent to the lawful processing of my data by the Sacco and recognize my rights regardingaccess, correction, deletion and transfer of my personal information. I also acknowledge that the Sacco has takenappropriate measures to ensure the security and confidentiality of my data.GENERAL MEMBERSHIP TERMS *Admission Info Membership:An applicant shall be admitted to membership but shall not qualifyfor the rights and privileges of membership until he/she has paid: -a) An entrance fee of KShs. 1000=b) Have a minimum Share Capital of KShs. 40,000/=.c) The minimum monthly contribution shall be 3,000 and shall befixed by the General Meeting from time to time.d) The society shares shall be non-refundablee) Refusal of admission: The Board may refuse admission to a personafter assigning reasons for their decision. Such a person shallhave the right to appeal to the next Annual General Meeting asprovided in the Act through a registered member.f) If a dispute arises at the time of a member's death, the proceedsshall be paid to the Public Trustees.g) A person of either gender shall be eligible for membership andshould possess the following qualifications:■ Is at least 18 years of age.■ Has not been convicted of a criminal offenceinvolving fraud or dishonesty.■ Is within the field of membership as approved inthe member policy.h) All members will automatically have a FOSA account uponregistration. The Minimum balance for FOSA account shall beKSh.500Cessation Of Membership:Membership of the society shall cease with effect from the date of a member’s:a) Deathb) Voluntary Withdrawal.c) Expulsion from societyd) Becoming certifiably insanee) Transfer of sharesf) Being declared bankrupt in a court of law.g) Ceasing to hold qualifications of members as stated in these by-lawsWithdrawal from the society:A member may at any time withdraw from the society by giving a written notice ofsixty (60) days, such member may re-apply for re-admission subject to the followingconditions, (a) He pays a registration fee of KShs. 1,000/- (One thousand shillings), (b)Nobody will be allowed to withdraw from the Society before clearing all loanbalances if any.Expulsion; *A member may be expelled or suspended by the General Meeting; Subject to thegrounds of expulsion contained in the Act, a member may be expelled on thefollowing grounds: -a) Where his/her activities are detrimental to the society's interest particularly if hemakes consciously untrue statements to the Board, the Supervisory committee orthe Ad hoc Committee or the Annual General Meeting.b) Where a member fails to fulfill any of his obligations to the society as required bythe applicable law.c) If he is convicted in a court of law of a criminal offence involving dishonesty orfraud or is imprisoned for a period of three months or more.d) Acts in any manner prejudicial or detrimental to the interest of the society.MOBILE BANKING TERMS *Definition Of Terms:“QONAPAY" refers to the mobile banking solution service.“PIN" means any confidential password, code, or number normally fourdigits which may be used to access the QONAPAY services.‘Transaction Fees” These are the QONAPAY transaction services charges.“24hr Service Hotline" Refers to the telephone number that will beprovided for QONAPAY customers in case of any queries related toQONAPAY services."Subscriber" means a customer who subscribes to use QONAPAY service.General ConditionsJoint account. Children, Corporate, and School FeesAccounts held jointly by two or more persons whose mandate is “anysign” accounts that require more than one signatory will NOT be issuedwith QONAPAY service.Use of Personal Identification Number (PIN)a) QONAPAY subscriber shall receive an SMS informing them of theirregistration and PIN.b) The Subscriber shall be required to Change the PIN before Using theQONAPAY Servicesc) The subscriber shall exercise due care to ensure the secrecy of the PINat all times and prevent use of PIN by any third party.d) In case of a problem the SACCO may at any time cancel/stop theservice without notice or assigning any reason and without incurringany liability to the subscriber until a solution is found.Lost/stolen SIM card registered for QONAPAY servicea) If the subscriber loses his/her SIM card line registered with QONAPAY,the subscriber must notify the SACCO immediately to blockQONAPAY service until the SIM card is replacedb) The subscriber shall be liable in respect of any transactions instructionsaffecting his/her SACCO account that is given with a valid PINc) If report of loss or theft of SIM card registered for QONAPAY service iscommunicated by someone other than the subscriber SACCO shallnot be held liable for any damages thereto.24 Hour Service HotlineThe 24hr service hotline is found on the SMS received when one is registered torQONAPAY service. Subscribers should keep the 24hr customer care number intheir mobile or frequently used telephone book.Forgotten PINIf a PIN is forgotten the subscriber is required to contact the SACCO to requestfor a new PIN.Cancellation, stoppage of QONAPAY servicea) The subscriber may at any time cancel or unsubscribe for QONAPAY service,b) Payments made by means of QONAPAY service are irrevocable.ChargesThe SACCO shall levy charges for use of this service. The subscriber shall beinformed of such changes by notice.Liability to the subscriberSubject to the above terms and conditions of use, subscribers shall be fully liablein respect of each transaction instruction.Acts That Do Not Bind Either PartyNeither party shall be liable for failure or delay in the performance of itsobligations under this agreement to the extent that such failure or delay iscaused by matters beyond that party's reasonable control including but notlimited to network delays destructions arising out of war, rebellion, civiliancommotion, strikes, lockouts and or other acts or orders of any governmentdepartment, council or other of constituted body. Notice of thesecircumstances shall be given to the other party as soon as possible. For so longas performance of those obligation is suspended the other party may similarlysuspend performance of its obligation.AmendmentThese terms and conditions may be amended at any time by notice from theSACCO to subscriber. The subscriber will be informed of such amendments bynotice at SACCO's branches. Any such amendments shall be deemed to beeffective and binding upon the subscriber upon publication of the notice.LawThese terms and conditions shall be governed and construed under laws of therepublic of KenyaEMAIL INDEMNITY *I do authorize within the framework of the functioning of QONA SACCO that Email instructions (if opted for) will beacted upon without any other written confirmation unless instructed otherwise.In consideration of the SACCO acting in accordance with the terms of this indemnity, the Member undertakes toindemnify the SACCO and to keep the SACCO indemnified against all losses, claims, actions, proceedings,demands, damages, costs, and expenses incurred or sustained by the SACCO of whatever nature and howsoeverarising, out of or in connection with such notices, demands or other communications, provided only that theSACCO acts in good faith, except where such losses, claims, actions, proceedings, demand, damages, costs andexpenses arise through the willful negligence of the SACCO.Such instructions will only originate from the email address provided (a pre-specified email address) whoseinstructions shall be complied with until otherwise advised in writing.I confirm that I have read, understood, and complied with all the membership requirements as per the bylaws andgeneral terms and conditions, I confirm that the particulars I have given are correct and true to the best of myknowledge.Upload signatureChoose FileNo file chosenDelete uploaded fileDateFOR OFFICIAL USE ONLYInput BySignatureStart signing your signature hereYour browser does not support e-Signature field.DateMonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212521242123212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925Authorized BySignatureStart signing your signature hereYour browser does not support e-Signature field.DateSubmit