LBMFT

Luton Bangladeshi Muslim Funeral Trust

1 Walsall Road, Luton LU4 9RA • www.lbmft.co.uk

Office Use Only
Memb ID:
Reg Date:
Processed by:

بسم الله الرحمن الرحيم

Membership Application Form

Important: All fields marked * are mandatory. Please write clearly in BLOCK CAPITALS. Misrepresentations may result in termination of membership.
Section 1 — Primary Applicant Personal Details
First Name *
Surname *
Marital Status *
Single Married Widowed Divorced
Date of Birth (DD/MM/YYYY) *
Gender *
Male Female
ID / Passport No
Address *
Postcode *
Town / City *
Mobile No *
Email Address *
Next of Kin
Full Name *
Relationship *
Phone Number *
Email
Primary Applicant Passport Photo Affix recent passport size photo here. Print full name on back.
Section 2 — Joint / Spouse Applicant Details (If Applicable)
First Name
Surname
Date of Birth (DD/MM/YYYY)
Gender
Male Female
ID / Passport No
Mobile No
Email Address
Spouse / Joint Applicant Photo Affix recent passport size photo here. Print full name on back.
Section 3 — Unmarried Dependants (Living Permanently at Same Address)
No. Full Name Date of Birth Gender (M/F) Relationship
1
2
3
4
LBMFT Official Form • Page 1 of 2
Section 4 — Confidential Medical Disclosures

Does any individual listed on this application profile suffer from a severe chronic or terminal illness?

YES NO

If YES, please provide details:

Section 5 — Membership Tier Selection & Documents

Membership Tier

Single Couple (Member + Spouse) Family (Member + Spouse + Dependants) Lifetime (£4,000 — Single only)

Age Group (circle one):

18–40 44–55 56–75

Mandatory Documents Attached

Passport-sized photographs Photo ID (passport / driving licence) Proof of address (utility bill / bank statement)
Section 6 — Trust Bank Account Details & Fee Schedule

Bank Transfer Details

Account Name: Luton Bangladeshi Muslim Funeral Trust
Sort Code: 23-05-80
Account No: 57955104
Reference: Your full name
Age Group Single / yr Couple / yr Family / yr Lifetime
18 – 40 years £60 £100 £150 £4,000
(Single only)
44 – 55 years £120 £200 £250
56 – 75 years £250 £350 £500

A one-time joining fee of £100 applies to all new members (except Lifetime). Annual fee + joining fee is payable on first application.

Section 7 — Formal Binding Declaration
I/We formally declare that all parameters logged across this application are fully factual and precise. I/We recognize that LBMFT operates as a community mutual support infrastructure and is not a commercial insurance provider. Relief allocants remain subject to Executive Committee validation. Misrepresentations regarding residency boundaries within Luton or pre-existing diagnoses may terminate registration and forfeit past contributions.

Primary Applicant Signature *

Date

Joint / Spouse Signature (if applicable)

Date

Section 8 — Office Use Only
Auditing Officer Signature Date
Verification: Payment Received Documents Verified Photo ID Checked
Decision: APPROVED REJECTED
Assigned Membership ID
LBMFT Official Form • Page 2 of 2 • LBMFT is not an insurance scheme. It operates as a community mutual support trust.