Membership

Membership Application

To,
Jeevan Jyoti Multistate Credit Co-op, Society Ltd.
Chennai - 600095

I request you to admit me as a member of your society & I furnish the following particulars:

Please correct the following errors:

1. Name in full:

Please enter your full name

Email Address:

Please enter a valid email address

Gender:

Please select your gender

2. Father's / Husband's Name:

Please enter father's/husband's name

3. Age:

Please enter a valid age (18-100)

Marital Status:

Please select marital status

4. Occupation:

Please enter your occupation

Annual Income (Rs):

Please enter your annual income

5. Residence Address:

Please enter your complete address

6. Aadhar No:

Please enter a valid 12-digit Aadhar number

PAN No:

Please enter a valid 10-character PAN number

Mobile No:

Please enter a valid 10-digit mobile number

Upload Photo:

Please upload a photo (JPEG, PNG, GIF, WEBP, max 1MB)

7. Whether an ex-member of the society

(a) Date of admission:

Please select admission date

(b) Membership No:

Please enter membership number

Please enter share taken

(d) Date of Discontinuance from membership:

Please select discontinuance date

(e) Reasons for discontinuance from membership:

Please enter reason for discontinuance

8. Number of shares required:

Please enter number of shares required

9. Share Capital Details

(a) Amount remitted towards share capital entrance fees:

Please enter amount remitted

(b) Date of remittance:

Please select remittance date

(d) Mode of remittance:

Please enter mode of remittance

10. Nominee Details:

(a) Name of the Nominee:

Please enter nominee name

(b) Relationship:

Please enter relationship with nominee

I declare that I am qualified to become a member of the society and I possess all the qualifications prescribed for membership of the society as per Multi State Co-operative Societies Act & Rules 2002 and the by-laws of the Society.

I also declare that the above particulars furnished by me are true to the best of my knowledge and belief.

Witnesses

1. Name and Address:

Please enter first witness details

2. Name and Address:

Please enter second witness details

Signature of the Applicant

Membership No:

Please enter applicant membership number

Date:

Please select application date