Document Sample
Membership_Renewal_Form_2012 Powered By Docstoc
					                                                                                                                                  The SEEP Network
                                                                                                                           Membership Renewal - Form 2011

                                                           Member Contact Information

Executive Director:                                                                                                                   Date:
                                       Last                          First                                       M.I.
Full Name of Organization:                                                                                       Website:

Official Representative1:                                                                                        E-Mail:

Secondary Contact2:                                                                                              E-Mail:

E mail contact to be displayed in our online directory:


City                                                                                       Country
   The Official Representative is SEEP’s main liaison with the member organization; he/she represents the organization, votes at the Annual General Meeting, and is the
primary point of contact.
   The secondary contact is someone in your organization who can assist with administrative tasks such as processing membership renewals, scheduling phone calls with
the Official Representative, etc.

                                                                       Member Profile

Select the type of your organization:

Please list the countries where you are present or represent.

Mission Statement

Does your organization have a consumer protection policy or code of conduct?                                                    Yes                   No

What services does your organization provide?
Financial Services                        Non-Financial Services
       Not applicable                                                Not applicable                              Business Development Services
       Loans                                                         Technical Assistance                        Capacity Building / Training
       Savings                                                       Financial Education                         Peer learning and exchange
       Insurance                                                     Policy Advocacy                             Credit Bureau
       Financial intermediation of funds                             Benchmark/ Transparency
     Management of funds for network             Market research / information dissemination
     strengthening                               Annual/ Bi-annual conference and industry events
     Financing projects that support new         Other, specify:
     innovation of products and services
     Other, specify:

Description of members / partners / affiliates (please submit list of members)
Please fill out the most updated statistics of your member institutions, partners, or affiliates:
     Not Applicable
Association / Organization Outreach
Indicator                                     Value                 Description
Number of members                                                   Total number of members
Members that are microfinance providers                             Number of members that are microfinance providers
For Associations Only:
Member ratio (%)                                                    # MFI members / Total #. MFIs in the market
Member coverage (%)                                                 Active clients of members/ Active clients in the market
Member / Affiliate Information
Indicator                                     Value                 Description
Gross Loan Portfolio (USD)
Gross Deposits (USD)
No. Active Borrowers
No. Active Depositors
No. Active Insured
% Women                                                             # of active clients who are women / # active clients
For Associations Only:
Rural Penetration (%)                                               % active clients from rural areas / % adult rural population

                                                      Topics of Interest

Please select the SEEP Communities of Practice that your organization would like to participate in (you may choose more
than one option).
Click here to learn more about each Community of Practice.
     Association Strengthening
     Financial Services
     Enterprise Development

Please indicate your topic of interest / expertise.
                                                                              My organization…
                                                                                                      Has products/services to
                                                Has initiatives in this    Wants to learning more
     Topics                                                                                             offer to other SEEP
                                                        topic                 about this topic
                                                                                                       members in this topic
     Agricultural and Rural Finance
     Consumer Protection
     Credit Bureau
     Financial Education
     Gender and Empowerment
     Health and Nutrition
     Housing Finance
     Impact Studies
     Islamic Finance
     Money Transfer and Remittances
     Microfinance in conflict affected areas
     Natural Disasters
     Poverty Outreach
     Social Enterprises
     Social Performance
     Technology / Mobile banking
     Value Chain
     Youth Financial Services

Please indicate other topics for future learning activities that your organization staff would be interested in:

Please indicate products / services your organization have to offer to other SEEP members and who is the clientele.

If you would like to have your organization's job directory posted in our website, please provide us the link to it:

                                                   Contribution to SEEP

Please estimate the number of hours your staff will dedicate to SEEP Learning Initiatives and how many travel dollars your
organization will spend in the coming year on SEEP Learning Initiatives including participating in Learning Initiative meetings,
research, writing, training, design or other work, SEEP Annual Conference, SEEP Annual General Meeting, SEEP Regional Conferences
                                                        Estimate Number of Days                  Estimate Total Dollar Value
Travel Time
Travel Expenses

            For New Members: In addition to the application form, submit the following documents
     In addition to this application form, please submit the following documents:
     1. A letter of application including the following information:
     a) An explanation of why the organization is interested in joining SEEP.
     For associations only: b) A description of your association’s most recent accomplishments in advancing the
     microfinance/enterprise development sector in your market.
2. A copy of the organizations most recent audited financial statements.
3. An organizational brochure or annual report.
4. A copy of the organization’s official letter of incorporation as a Charity/Non-Profit.

                                                       Thank you!

Shared By: