| MEMBERSHIP APPLICATION |
| ACCOUNT TYPE |
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All of the terms, conditions, form of account ownership, account selection and other information indicated on application apply to all of the accounts listed below unless the credit union is notified in writing of a change.
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Suffix* |
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Suffix* |
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Share/Savings |
________________ |
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Money Market |
________________ |
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Share Draft/ Checking |
________________ |
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Living Trust |
________________ |
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Share Certificate |
________________ |
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Other |
________________ |
| *The account number for each of the accounts listed above consists of the suffix added to the end of the Member Number listed below. If this application applies to more than one account of the same type, more than one suffix will be listed for that account type. |
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| MEMBER APPLICATION AND OWNERSHIP INFORMATION |
| MEMBER/OWNER |
MEMBER NUMBER |
| STREET |
SSN/TIN |
| CITY/STATE/ZIP |
DRIVER'S LICENSE NUMBER |
HOME PHONE
( DFGDG )) )) |
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LISTED |
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UNLISTED |
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DATE OF BIRTH |
| PASSWORD |
WORK PHONE
(KSDFKSDJF) |
EMPLOYMENT |
| EMAIL |
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| TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION |
Under penalties of perjury, I certify that:
(1) The number shown on this application is my correct taxpayer identification number,
(2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
(3) I am a U.S. person (including a U.S. resident alien.
Certification Instructions. Cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. Cross out item 3 and fill out a W-8 BEN if you are not a U.S. person. |
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| AUTHORIZATION |
By signing below, I/we agree to the terms and conditions of the Membership and Account Agreement, Truth-In-Savings Rate and Fee Schedule, Funds Availability Policy Disclosure, if applicable, and to any amendment the Credit Union makes from time to time which are incorporated herein. I/We acknowledge receipt of the Agreement and Disclosures applicable to the accounts and services requested herein. If an access card or EFT service is requestedand provided, I/we agree to the terms of and acknowledge receipt of the Electronic Funds Transfer Agreement. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.
| X |
_________________________________________________ |
X |
_______________________________________________ |
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Signature ksdfkdsjfdfdhf dfgkj Date |
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Signature sdfkdsjflksjfdfdfkdf Date |
| X |
_________________________________________________ |
X |
_______________________________________________ |
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Signature ksdfkdsjfdfdhf dfgkj Date |
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Signature sdfkdsjflksjfdfdfkdf Date |
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| ACCOUNT SERVICES |
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Payroll Deduction/Direct Deposit |
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Debit Card ___________________________________ |
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Overdraft Protection (Indicate transfer priority below)
____________________________________________ |
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Audio Response _______________________________ |
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PC Access/Internet Banking ____________________ |
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Other ________________________________________ |
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ATM Card ___________________________________ |
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| ACCOUNT OWNERSHIPS |
| Designate the ownership of the accounts and responsibility for the services requested. |
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Individual |
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Joint Account with Survivorship |
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Joint Account without Survivorship |
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| JOINT OWNER |
MEMBER NUMBER |
| STREET |
SSN/TIN |
| CITY/STATE/ZIP |
DRIVER'S LICENSE NUMBER |
HOME PHONE
( DFGDG )) )) |
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LISTED |
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UNLISTED |
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DATE OF BIRTH |
| PASSWORD |
WORK PHONE
(KSDFKSDJF) |
EMPLOYMENT |
| EMAIL |
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| JOINT OWNER |
MEMBER NUMBER |
| STREET |
SSN/TIN |
| CITY/STATE/ZIP |
DRIVER'S LICENSE NUMBER |
HOME PHONE
( DFGDG )) )) |
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LISTED |
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UNLISTED |
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DATE OF BIRTH |
| PASSWORD |
WORK PHONE
(KSDFKSDJF) |
EMPLOYMENT |
| EMAIL |
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| ACCOUNT DESIGNATIONS |
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Payable on Death (POD)/Trust Account |
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All Accounts |
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Designate Specific Accounts |
| BENEFICIARY/POD PAYEE (last - first - Initial) |
BENEFICIARY/POD PAYEE |
| STREET |
STREET |
| CITY/STATE/ZIP |
CITY/STATE/ZIP |
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|
AGENCY |
PRINT NAME OF AGENT
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Signature:
X__________________________________________________________________________________
sgfdhgfjhgfhkjhljk;lk;l;';lk'dgfldkagjslklj'Date
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All Accounts |
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Designate Specific Account(s) ___________________________________ |
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UTTMA/UGMA (as custodian for _________________________________________ (minor) under the Uniform |
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Transfers/Gifts to Minors Act) |
Minor's TIN/SSN____________________________ |
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OTHER_________________________________________ |
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See Account Authorization Card |
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| For Credit Union Use Only |
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See Account Authorization Card |
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See Insurance Benificiary Card |
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| Date of Membership __________________ |
Opened/App'd by________________ |
hjhlMember Verification____________________ |
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Credit Report |
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Check Verify |
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PIN Request |
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Access Card |
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Audio Response |
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PC Access/Internet Branching |
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You Must Print, Sign, and Return to Credit Union along with membership fee*,
copy of your drivers license and copy of your social security card
*Please include $10 with application: $5 for membership fee and $5 for initial deposit into Share account.
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