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Membership Application

Please complete all requested information and then submit the form as indicated at bottom of page. You will be contacted regarding the status of your application.

Important Information About Procedures for Opening a New Account

To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

* - Indicates required field

Account Type

All of the terms, conditions, form of account ownership, account selection and other information on this application applies to all of the accounts listed below unless the credit union is notified in writing of a change.

Account Type
Account Type

*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 card applies to more than one account of the same type more than one suffix will be listed for that account type.

Application and Ownership Information

Account Services

Do you desire the following types of Services? (must select one or more)

 
Indicate transfer priority
 

Account Ownership

Designate the ownership of accounts and responsibility for the services requested.

*Account Ownership

Joint Owner #1 Information

Joint Owner #2 Information

Account Designations

*Account Designations



Beneficiary #1

Beneficiary #2

Agency Designation

All Accounts (if no, specify)

UTTMA/UGMA (under the Uniform Transfers/Gifts to Minors Act) Designation

Other Designation

TIN Certificate and Backup Withholding Information

* Under penalties of perjury, I certify that:

Certification Instructions. Check 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. Check item (3) and complete a W-8 BEN if you are not a U.S. person.

Electronic Signature & Authorization

* By checking the "I agree" box, 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 an 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 card or EFT service is requested and provided, I/we agree to the terms of an acknowledged receipt of the Electronic Funds Transfer Agreement. The Internal Revenue Service does not require your consent to any provision of the document other than the certifications required to backup withholding.

*Prove you're not a robot