Bold Text APPLICANT DETAILS (as per ID or Passport) TitleMr.Mrs.Ms.Dr.Prof.Hon.Other.First Name *Surname *OthernamesIdentification DocID NoPasport NoNational ID / Passport No: *Nationality *Phone *Email Address *Street Address *City *ZIP/Postal Code *Country *Upload 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? *MobileEmailBoth Bold Text QONAPAY / iCONNECT REGISTRATION Funds 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 *Go to the Mpesa Menu. Select Lipa Na M-Pesa and then Paybill. Enter Qona Sacco Business number 505100. Enter your Account Number (National ID) followed by the letter ‘REG’ . Confirm your details. Enter the Amount and your Mpesa Pin. Wait for a confirmation message from Qona Sacco. Rea Bold Text EMPLOYMENT DETAILS EmployerOccupation:Employee PositionStaff No :Gross Income Per Month (KSh):Below 100K100-499K500K- 999K1M-3MAbove 3M Bold Text IF JOINING AS AN INDIVIDUAL FILL IN PHYSICAL LOCATION OF BUSINESS & POSTAL ADDRESS Nature of Business eg. Law firm:Business Name:Physical Location of Business:Business Email Address:Business Registration No:Gross Income Per Month (KSh):Below 100K100-499K500K- 999K1M-3MAbove 3M Bold Text WHO INTRODUCED YOU TO QONA SACCO? Referral Member Name:Member No:Social MediaXInstagramFacebookYouTubeWEBWebsiteGoogle Search Bold Text NEXT OF KIN DETAILS I 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.Nominated Next of KINRelationshipSpouseSonDaughterBrother/SisterFatherMotherName *Date of Birth *Percentage of next of kin *ID numberPhone *Nominated Next of KINRelationshipSpouseSonDaughterBrother/SisterFatherMotherName *ID numberPercentage of Next of kin *Date of BirthPhone * Bold Text REMMITANCES I 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 *Employer (Check-Off)Standing OrderFOSA Standing OrderCash Over the CounterLipa na M-PESADATA PROTECTION ACKNOWLEDGEMENT & CONSENT *View Data Protection Acknowledgement & Consent MOBILE BANKING TERMS *Visit Mobile Banking TermsGENERAL MEMBERSHIP TERMS *Visit General Membership TermsEMAIL INDEMNITY *Visit Email IndemnityUpload signature *Choose FileNo file chosenDelete uploaded fileDate *Submit
