Central Death Committee

Application Form for Membership of Central Death Committee

Section A (to be completed by the applicant)
Application Date*

DayMonthYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Email*
example@example.com
Home Number
Mobile Number*
Required
Gender*
Date of Birth*

DayMonthYear
Date
Marital Status*

Details of children under the age of 16 years and Spouse if married (resident in Luton, United Kingdom)

Please give details of any Medical Conditions for all people on the form. *
I confirm that myself and anyone else on this form is not terminally ill and I have listed all the medical conditions.
I understand that I will not be covered for any deathin the first year unless it is accidental/sudden.
I the undersigned do solemnly declare that the information given on this form is correct. I will abide by the rules and regulations of the central death committee. A copy of which I have received.*

I give consent to the Islamic Cultural Society to use my information for the purposes of the Death Committee and contact me for Feedback.
Sign*

Clear
Date*

DayMonthYear
Date
We need proof of ID(passport, driving licence, Birth Certificate) and Proof of Address for all the people on the form. Please ensure the pictures of the documents are clear and readable.*

Cancelof
Should be Empty: