FORM - Details of changes

Mutual Societies Application Form

Notice of Change of Chief Executive,

Secretary, Director and/orCommittee Member

Form

Mutual Societies Application Form

Notice of Change of Chief Executive,

Secretary, Director and/orCommittee Member

Form

/ Details of changes

Society details

1 Society Details

Register number

Details of changes

2 Are you informing us of an appointment(s) and/or cessation(s)?

Appointment(s)Complete questions 3 and 5

Cessation(s)Complete questions 4 and 5

Appointment(s) and Cessation(s)Complete questions 3, 4 and 5

Details of appointment(s)

3 Details of individual(s)

Please use separate sheets of paper if you need more space.

Please indicate how many separate sheets of paper you have used for this question.

Director

Committee Member

Chief Executive

Secretary (only for friendly societies)

Chief Executive and Secretary (only for friendly societies)

Full name
Address
Postcode
Date of birth / dd/mm/yy / You must provide the individual's date of birth if your society is a Friendly Society notifying us of a change of Committee Member.
Date of appointment / dd/mm/yy

Director

Committee Member

Chief Executive

Secretary (only for friendly societies)

Chief Executive and Secretary (only for friendly societies)

Full name
Address
Postcode
Date of birth / dd/mm/yy / You must provide the individual's date of birth if your society is a Friendly Society notifying us of a change of Committee Member.
Date of appointment / dd/mm/yy

Director

Committee Member

Chief Executive

Secretary (only for friendly societies)

Chief Executive and Secretary (only for friendly societies)

Full name
Address
Postcode
Date of birth / dd/mm/yy / You must provide the individual's date of birth if your society is a Friendly Society notifying us of a change of Committee Member.
Date of appointment / dd/mm/yy

Director

Committee Member

Chief Executive

Secretary (only for friendly societies)

Chief Executive and Secretary (only for friendly societies)

Full name
Address
Postcode
Date of birth / dd/mm/yy / You must provide the individual's date of birth if your society is a Friendly Society notifying us of a change of Committee Member.
Date of appointment / dd/mm/yy

Director

Member of Committee

Chief Executive

Secretary (only for friendly societies)

Chief Executive and Secretary (only for friendly societies)

Full name
Address
Postcode
Date of birth / dd/mm/yy / You must provide the individual's date of birth if your society is a Friendly Society notifying us of a change of Member of Committee.
Date of appointment / dd/mm/yy

Details of cessation(s)

4 Details of individual(s)

Please use separate sheets of paper if you need more space.

Please indicate how many separate sheets of paper you have used for this question.

Director

Member of Committee

Chief Executive

Secretary (only for friendly societies)

Chief Executive and Secretary (only for friendly societies)

Full name
Address
Postcode
Date of cessation / dd/mm/yy

Director

Member of Committee

Chief Executive

Secretary (only for friendly societies)

Chief Executive and Secretary (only for friendly societies)

Full name
Address
Postcode
Date of cessation / dd/mm/yy

Director

Member of Committee

Chief Executive

Secretary (only for friendly societies)

Chief Executive and Secretary (only for friendly societies)

Full name
Address
Postcode
Date of cessation / dd/mm/yy

Director

Member of Committee

Chief Executive

Secretary (only for friendly societies)

Chief Executive and Secretary (only for friendly societies)

Full name
Address
Postcode
Date of cessation / dd/mm/yy

Director

Member of Committee

Chief Executive

Secretary (only for friendly societies)

Chief Executive and Secretary (only for friendly societies)

Full name
Address
Postcode
Date of cessation / dd/mm/yy

Signature

5 The Secretary of the society must sign and date below

Signature
Date / dd/mm/yy

End of form

FCA Mutuals Notice of Appointment and/or Cessation (F) Release 1  April 2013page 1