Online Credit Union Membership Application

Please fill out the account card below - you can either print it out and fill in the requested information, or fill it out online and we will recieve it in our office the next business day. Either way, you will still need to come by the office to bring us a copy of a picture ID.
MEMBER APPLICATION AND OWNERSHIP INFORMATION
Name
First Middle Last
Member Number Security Code
Street SSN/TIN

000-00-0000
City Driver's License Number
State Date of Birth
\  \
mm
dd
yyyy
Zip Email
Home Phone
Listed Unlisted
    000-000-0000
Work Phone

000-000-0000
 
Employment
Eligibility for Membership
 
TIN CERTIFICATION AND BACKUP WITHHOLDING INFORMATION
Under penalty of perjury, I certify that ALL of the following are true:
1. The Social Security or Taxpayer ID Number entered on this form 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 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).
 
By answering YES I certify, under penalty of perjury,
that ALL of the above statements are true:
No     Yes

If you answered NO above, please explain under penalty of perjury
which statements are not true and describe your current situation:
 
AUTHORIZATION
By submitting this application, 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 a copy of the Agreement and Disclosures applicable to the accounts and services requested herein.  If an access cart or EFT service is requested and 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.


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