ICEA Housing Co-operative Society

I. Personal Information

Title: *

Mr.

Mrs.

Miss

Dr.

Prof.

Hon.

First Name: *

Last Name: *

Other Names:

ID/ Passport Number *

National ID (Front) *

National ID (Back) *

Nationality *

Phone Number*

Email*

City/ Town*

Postal Address*

Code*

How would you like to receive membership confirmation? *

Email

II. Employment Details

Employer

Occupation

Employee Position

Staff No

Gross Income Per Month (Ksh):

Below 100K

100-300K

300-500K

500K-1M

1M-3M

Above 3M

II. Next of Kin Details

Nominated Next of Kin *

Relationship *

ID/ Passport Number *

Date of Birth *

Phone Number *

Percentage (%) assigned *

IV. Payment Details

Preferred mode of Payment *

Employer (Check-Off)

Cash Over the Counter

Standing Order

Lipa na M-PESA

FOSA Standing Order

Monthly Deposits (Ksh)*

Share Capital Contributions (Ksh) *

Month *

Remmitances *

I hereby authorize you to deduct Ksh(monthly Deposits) Monthly Deposits contribution and Ksh(share capital contribution) share capital contribution from my salary and/or any other mode of Remittance and pay ICEA Housing Co-operative Society Ltd with effect from the selected month until further notice. Membership fee of Ksh2000(for ICEA Agents and staff, or Ksh5000 for public members) will be deducted with the 1st deduction from payroll OR any other mode of remittance arrangement with the society.