Membership Application

Status in Canada*

Member ID (For office use only)

Prefix*

First Name*

Last Name*

Date of Birth*

Gender*

Address*

City*

Province*

Postal Code*

Home Phone

Cell Number*

Email*

Emergency Contact Person Name - 01*

Relation*

Tel/Cell*

Emergency Contact Person Name - 02*

Relation*

Tel/Cell*

Spouse

First Name

Last Name

Date of Birth

Gender

Home Phone

Cell Number

Dependent Children (under 19 only)

List

First Name

Last Name

Date of Birth

Gender

Pre-Authorized Payment Plan

I, the Principal Applicant, do hereby authorized the FSSO to draw the reimbursement share amount to cover funeral cost of deceased member of the organization as and when needed from my under mentioned account up to the limit of $15.00 per case. I further authorize FSSO to withdraw any past due payment along with penalty from my valid account.

Name of the Bank*

Account Number*

Branch Code*

Name of Account Holder*

Sponsor Name

Date*

Attach Void Cheque (Must be PDF or JPG format)*

Drop files here or

Max. file size: 64 MB.

Payment Proof (Must be PDF or JPG format)*

Drop files here or

Max. file size: 64 MB.

Canada Status Proof (Must be PDF or JPG format)*

Drop files here or

Max. file size: 64 MB.

We would appreciate if you kindly give us your feedback.

How did you hear about FSSO (Funeral Support Services Organization)? (Check all that apply)

Grocery*

Masjid*

Other

Acknowledgement*

I, the Principal Applicant by clicking the submit button below, hereby acknowledge and confirm that I have carefully read, fully understood and agreed with the terms and conditions and policies of FSSO (Funeral Support Services Organization).

Additional Information

Principal Applicant

Spouse

Dependent Children (under 19 only)

Pre-Authorized Payment Plan

We would appreciate if you kindly give us your feedback.

CONTACT INFO