Membership Application

Please complete all requested information and then submit 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.

Account Type
All of the terms, conditions, form of account ownership, account selection and other information on this application apply to all of the account listed below unless the credit union is notified in writing of a change.
    Suffix*     Suffix*
*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
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Account Services
Do you desire the following types of Credit Insurance? (must select one or more)
 
     
Account Ownership
Designate the ownership of accounts and responsibility for the services requested
Joint Owner #1 Information
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Joint Owner #2 Information
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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:
(1) The number shown 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 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. Check the (2) item 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 the (3) item 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 incorporate 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 acknowledge 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.