Page 1 Page 2 Page 3 Page 4 Order Number Membership Application Form This membership application form will be completed in different stages. The information that you provide will be used solely for the purpose of JN Circle and your personal information will not be shared with external parties. To be completed by nominator and signed by both the nominator and the nominee Title * Mr. Ms. Mrs. Dr. Rev. First Name * Middle Name * Surname * Home Address * Home Telephone Mobile Business/Employer's Name Position Title or Description Business Address Business Telephone Fax Email Address * Date of Birth * Wedding Anniversary Spouse's Name Association with any Service Club/Charity Some vocational and personal background details that will enhance your activities as a JN Circle member How are you affiliated with the JN Group? * Member Advisory Council Member JN Group Employee JN Bank Member JN Fund Managers Customer JN General Insurance JN Small Business loans Customer JN Money Services Customer JN Life Insurance Customer Jamaica Automobile Association Customer Other Tick all that apply To become a member of JN Circle you must have an active JN Bank account. If you are not yet a JN Bank Member, will you open an account within 2 months of submitting this application? Active JN Bank Account? * Yes No Other History Have you ever been charged or convicted of a crime? * Yes No If yes, please explain: I hereby certify that the information provided herein is true and accurate as at the date hereof and further, if accepted to Membership of the JN Circle of , that I as a JN Circle Member will exemplify the Object of the JN Circle and the values of The Jamaica National Group in all my daily contacts and will abide by the Constitutional documents of the JN Circle. Further, I understand that I have sole responsibility for my actions and their repercussions at all times. In consideration of being permitted to participate in the JN Circle : I AGREE to assume full responsibility for any risk, injuries, damage, whether known or unknown, and to hold harmless, release, defend and indemnify JN Group thereof, the employees, agents and associates from any liability, claims, demands, damages, interest, expenses, actions and causes of actions whatsoever arising from or related to any property damage or loss, personal injury, death or any other loss or damage whatsoever caused by or howsoever sustained or arising during, from or in relation to my participation in said program. I AGREE that JN Group, its agents and/or associates may use my name and likeness, including any photographs, videos in which my image may appear to endorse or promote JN Group, its agents and/or associates. Constitutional Agreement * I Agree I hereby certify that if accepted to Membership of the JN Circle of , that I as a JN Circle Member will exemplify the Object of the JN Circle and JN National Group in all my daily contacts and will abide by the Constitutional documents of JN Circle. I agree to pay an admission fee and annual dues in accordance with the bylaws of the JN Circle. I hereby give permission to the JN Circle to publish my name and other particulars to its membership once I become a member. Membership Agreement * I Agree Nominator's Signature: * Nominee's Signature: * Nominee date sign Signature Signature Date
