MEMBERSHIP APPLICATION
ACCOUNT TYPE

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.

   
Suffix*
   
Suffix*
   
Share/Savings ________________
   
Money Market ________________
   
Share Draft/ Checking ________________
   
Living Trust ________________
   
Share Certificate ________________
   
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.
MEMBER APPLICATION AND OWNERSHIP INFORMATION
MEMBER/OWNER  MEMBER NUMBER
STREET  SSN/TIN
CITY/STATE/ZIP DRIVER'S LICENSE NUMBER
HOME PHONE
( DFGDG )) ))
   
   
LISTED
   
UNLISTED  
DATE OF BIRTH
PASSWORD
WORK PHONE
(KSDFKSDJF)
 EMPLOYMENT
EMAIL
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.

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 _______________________________________________
  Signature                                 ksdfkdsjfdfdhf dfgkj Date   Signature                             sdfkdsjflksjfdfdfkdf    Date
X _________________________________________________ X _______________________________________________
  Signature                                 ksdfkdsjfdfdhf dfgkj Date   Signature                             sdfkdsjflksjfdfdfkdf    Date
ACCOUNT SERVICES
   
Payroll Deduction/Direct Deposit  
   
Debit Card ___________________________________
   
Overdraft Protection (Indicate transfer priority below)
____________________________________________
 
   
Audio Response _______________________________
   
PC Access/Internet Banking ____________________  
   
Other ________________________________________
   
ATM Card ___________________________________      

 

ACCOUNT OWNERSHIPS
Designate the ownership of the accounts and responsibility for the services requested.
   
Individual
   
Joint Account with Survivorship
   
Joint Account without Survivorship
           
JOINT OWNER  MEMBER NUMBER
STREET  SSN/TIN
CITY/STATE/ZIP DRIVER'S LICENSE NUMBER
HOME PHONE
( DFGDG )) ))
   
   
LISTED
   
UNLISTED  
DATE OF BIRTH
PASSWORD
WORK PHONE
(KSDFKSDJF)
 EMPLOYMENT
EMAIL
JOINT OWNER  MEMBER NUMBER
STREET  SSN/TIN
CITY/STATE/ZIP DRIVER'S LICENSE NUMBER
HOME PHONE
( DFGDG )) ))
   
   
LISTED
   
UNLISTED  
DATE OF BIRTH
PASSWORD
WORK PHONE
(KSDFKSDJF)
 EMPLOYMENT
EMAIL
ACCOUNT DESIGNATIONS
   
Payable on Death (POD)/Trust Account
   
All Accounts
   
Designate Specific Accounts
BENEFICIARY/POD PAYEE (last - first - Initial) BENEFICIARY/POD PAYEE
STREET STREET
CITY/STATE/ZIP CITY/STATE/ZIP
   
AGENCY PRINT NAME OF AGENT
Signature:
X__________________________________________________________________________________
  
                                                         
sgfdhgfjhgfhkjhljk;lk;l;';lk'dgfldkagjslklj'Date
                                                                     
 
   
All Accounts
   
Designate Specific Account(s) ___________________________________
 
   
UTTMA/UGMA (as custodian for _________________________________________ (minor) under the Uniform
  Transfers/Gifts to Minors Act) Minor's TIN/SSN____________________________
 
   
OTHER_________________________________________
   
See Account Authorization Card
For Credit Union Use Only
    
   
See Account Authorization Card
   
See Insurance Benificiary Card
Date of Membership __________________ Opened/App'd by________________ hjhlMember Verification____________________
 
   
Credit Report  
   
Check Verify  
   
PIN Request
 
   
Access Card  
   
Audio Response  
   
PC Access/Internet Branching

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.