Membership Application

Principal Applicant

Applicant Form

Status in Canada

ABSAA ID (only for office use)

First Name

Last Name

Date of Birth

Gender

Address

City

Province

Postal Code

Home Phone

Cell Number

Emergency Contact Person Name - 01

Emergency Contact Person Name - 02

Relation 01

Relation 02

TEL/CELL 01

TEL/CELL 02

Spouse

Spouse First Name

Spouse Last Name

Date of Birth

Gender

Home Phone

Cell Number

Upload Spouse picture Id

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Dependents

Dependent First Name

Dependent Last Name

Relation

Date of Birth

Gender

Upload dependent picture Id

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Dependent First Name

Dependent Last Name

Relation

Date of Birth

Gender

Upload dependent picture Id

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Dependent First Name

Dependent Last Name

Relation

Date of Birth

Gender

Upload dependent picture Id

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Dependent First Name

Dependent Last Name

Relation

Date of Birth

Gender

Upload dependent picture Id

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Dependent First Name

Dependent Last Name

Relation

Date of Birth

Gender

Upload dependent picture Id

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Pre-Authorized Payment Plan

I, the Principal Applicant, do hereby authorize Al-Widaa Burial Support Association of Alberta (ABSAA) to withdraw the reimbursement share amount from my designated bank account to cover funeral costs of any deceased member of the organization, as and when required, up to a maximum of $15.00 per member. I further authorize ABSAA to withdraw if any registration fees, outstanding dues, and applicable penalties from my designated bank account.

Name of the Bank

Account Number #

Transit #

Financial institution #

Name of Account Holder

Sponsor Name (Principal applicant)

Effective Date

Document Uploads

Attach Void Cheque (Must be PDF or JPG format)

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Send Your e-Transfer Payment To:

absaaedmonton@gmail.com

E-transfer payment proof (E- transfer service will be temporarily till bank allows automatic electronic payment)

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Canada status proof / picture id (Must be PDF or JPG format)

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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 ABSAA (AL-WIDAA BURIAL SUPPORT ASSOCIATION OF ALBERTA )

Sample Void Cheque

For reference only. Make sure your cheque clearly shows the bank name, transit number, institution number, and account number.

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