Membership Application Member Name* Address* City, State, Zip* Email* Date Of Birth*01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Home Phone* Work Phone* Mobile Phone* Employer* Job Position* Employer Address* Designate the ownership of the accounts and responsibility for the services requested.*IndividualJoint with Rights of SurvivorshipJoint without Rights of Survivorship Joint Owner 1 Address 1 City, State, Zip 1 Home Phone 1 Work Phone 1 Mobile Phone 1 Date of Birth 101020304050607080910111213141516171819202122232425262728293031day/JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth/202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Email 1 Joint Member 2 Address 2 City, State, Zip 2 Work Phone 2 Home Phone 2 Mobile Phone 2 Date of Birth 201020304050607080910111213141516171819202122232425262728293031day/JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth/202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Email 2 Joint Member 3 Address 3 City, State, Zip 3 Home Phone 3 Work Phone 3 Mobile Phone 3 Date of Birth 301020304050607080910111213141516171819202122232425262728293031day/JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth/202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901year Email 3 Designations*Payable at Death (POD)/Trust AccountAll Accounts Beneficiary/POD Payee 1* Address POD1* City, State, Zip POD1* UTMA/UGMA (as custodian for minor under the Uniform Transfers/Gifts to Minors Act)Click if YES Minor's Full Name Designations MinorPayable at Death (POD)/Trust AccountAll Accounts Designate Specific Accounts Beneficiary/POD Payee 2 Address POD2 City, State, Zip POD2 Agency / Name of Agent Signature (Initials) Designate Specific Accounts Minor Account Type A)*Share/Savings AccountShare Draft/Checking AccountShare Sertificate/Certificate Account Type B)Money MarketHSAOther Please Specify if Selected Other Services A)Payroll Deduction/Direct DepositAudio ResponseOverdraft Protection Services B)ATM CardDebit CardOnline BankingUnder penalties of perjury, I certify that:(1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued), and(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. citizen or other U.S. person. For federal tax purposes, you are considered a U.S. person if you are: an individual who is a U.S. citizen or U.S. resident alien; a partnership, corporation, company, or association created or organized in the United States or under the laws of the United States; an estate (other than a foreign estate); or a domestic trust (as defined in Regulations section 301.7701-7).(4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.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. Complete a W-8 BEN if you are not a U.S. person. If a W-8 BEN is completed, your signature does not serve to certify this section. Exempt Payee Code (If Any) Exemption From FACTA Reporting Code (If Any)By signing below, I/we agree to the terms and conditions of the Membership and Account Agreement, Truth-in-Savings Disclosure, Funds Availability Policy Disclosure, if applicable, and to any amendment the Credit Union makes from time to time which are incorporated herein. I/We have received and read the agreements 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 and acknowledge receipt of the Electronic Fund Transfers Agreement and Disclosure. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.INSERT INITIALS FOR SIGNATURES BELOW Signature* Date* Signature 2 Date 2 Signature 3 Date 3 Signature 4 Date 4 Insert Security Code & SUBMITSubmitReset25791
