Membership Application

Member Application and Ownership Information

(*) indicates a required field

Disclosures*

Yes, I've read and agree to the following:

You must agree to the disclosures to proceed!

For your convenience, we will automatically send you PDFs of our disclosures after you’ve successfully submitted your application.

First Name*

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Middle Name

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Last Name*

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Street (cannot be a P.O. Box)*

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City*

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State*

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Zip Code*

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Is your email address different than above?

Check here if your mailing address is different than above

You must agree to the disclosures to proceed!

Mailing Address*

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City*

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State*

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Zip Code*

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Primary Phone Number*

Please enter your primary phone number

Secondary Phone Number

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E-Mail Address*

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Social Security Number/TIN*

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ID Type*

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State Issued ID Number*

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State of Issue*

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Expiration Date*

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Passport Number*

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Expiration Date*

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Birthdate (MM/DD/YYYY)*

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Mother's Maiden Name*

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Membership Eligibility*

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Elegibility Information*

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Account Ownership

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

Account Ownership*

Individual

Joint

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Joint Owner Information

First Name*

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Middle Name

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Last Name*

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Physical Address*

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City*

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State*

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Zip/Postal Code*

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is your mailing address different than above?

Check here if your mailing address is different than above

You must agree to the disclosures to proceed!

Mailing Address*

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City*

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State*

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Zip/Postal Code*

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Primary Phone Number*

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Secondary Phone Number

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Social Security Number*

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ID Type*

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State Issued ID Number*

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State of Issue*

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Expiration Date*

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Passport Number*

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Expiration Date*

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Birthdate (MM/DD/YYYY)*

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Mother's Maiden Name*

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E-Mail Address*

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Would you like to add another Joint Owner?*

Yes

No

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First Name*

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Middle Name

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Last Name*

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Physical Address*

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City*

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State*

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Zip/Postal Code*

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is your mailing address different than above?

Check here if your mailing address is different than above

You must agree to the disclosures to proceed!

Mailing Address*

Invalid Input

City*

Invalid Input

State*

Invalid Input

Zip/Postal Code*

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Primary Phone Number*

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Secondary Phone Number

Invalid Input

Social Security Number*

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ID Type*

Invalid Input

State Issued ID Number*

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State of Issue*

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Expiration Date*

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Passport Number*

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Expiration Date*

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Birthdate (MM/DD/YYYY)*

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Mother's Maiden Name*

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E-Mail Address*

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Account Designations

Payable-On-Death Account Beneficiary Designation

Upon the death of the last surviving owner, the funds in Your Account shall become the property of the beneficiary(ies) listed below who are alive at that time. You may change the beneficiary(ies) identified below only with the written consent of all owners to the Account.

Please note: If you elect multiple beneficiaries and you do not allocate percentages to each beneficiary, the funds will be split equally among the surviving beneficiaries.

Designations

Payable on Death (POD)/Trust Account

All Accounts

Designate Specific Accounts

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Which Accounts?*

Checking

Savings

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Number of beneficiaries*

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First Beneficiary/POD Payee*

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Address*

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City*

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State*

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Zip/Postal Code*

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Social Security Number*

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Birthdate (MM/DD/YYYY)*

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Percentage

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Name of 2nd Beneficiary*

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Address*

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City*

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State*

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Zip/Postal Code*

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Social Security Number*

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Birthdate (MM/DD/YYYY)*

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Percentage

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Please note the percentages allocated to your beneficiaries must equal 100 percent in order to submit your application.

Account Type

All of the terms, conditions, form of account ownership, account selection and other information indicated on this form apply to all of the accounts listed unless the Credit Union is notified in writing of a change.

Account Type(s)*

Share/Savings (Required for Membership) - $15 ($5 Min. Deposit and $10 Membership Fee)

Share Draft/Checking

Share Certificate/Certificate

Money Market

HSA

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The account number for each of the accounts listed consists of the suffix added to the end of the Member Number listed in the "MEMBER APPLICATION AND OWNERSHIP INFORMATION" section. If this form applies to more than one account of the same type, more than one suffix will be listed for that account type.

Account Services

Check All That Apply*

Taxpayer Identification Number Certification and Backup Withholding Information

Have been notified by the IRS that you are currently subject to backup withholding because you failed to report all interest and dividends on your tax return?

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Are you a US Citizen?

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You have answered that you are NOT a US citizen. Please provide a completed IRS W-8 BEN Form.

Check the following

(1) The number shown on this form is my correct taxpayer information 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, and

(3) I am a U.S. citizen or other U.S. person (including U.S. resident alien)

(4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

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We will be unable to open an Account for You without a taxpayer identification number.

Exempt payee code (if any)

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Exemption from FATCA reporting code (if any)

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Authorization

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 acknowledge receipt of a copy of 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.

I Agree

Customer Due Diligence Questionnaire

IDENTIFICATION

First Name*

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Last Name*

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INTERPRETER

Is there an interpreter or someone speaking on the behalf of the customer?*

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GENERAL INFORMATION

What is your employment status?*

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What is your occupation?*

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Are you a frequent traveler?*

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DECLARED BEHAVIOR

Will the initial deposit exceed $5000?*

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Will you deposit or write checks?*

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Will you deposit or withdraw cash?*

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Approximately how much cash do you expect to deposit each month?*

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Approximately how much cash do you expect to withdraw each month?*

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Will you send or receive wire transactions?*

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Will you send or receive electronic/ACH (non-wire) transactions?*

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POLITICALLY EXPOSED PERSONS (PEP)

Are you currently, or have you ever been a Politically Exposed Person (PEP) or a senior political figure?*

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Are you an immediate family member or a close associate of someone who is currently, or who was, a PEP?*

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I Agree

Member Application and Ownership Information

Account Ownership

Joint Owner Information

Account Designations

Payable-On-Death Account Beneficiary Designation

Account Type

Account Services

Taxpayer Identification Number Certification and Backup Withholding Information

Authorization

Customer Due Diligence Questionnaire

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